Depression is the most common mental illness in America, and it is the leading cause of disability worldwide. Major depression disorder, often shortened to just depression, is more than just feeling sad. Everyone feels sad or even mildly depressed at times, especially after a death, relationship breakup, problems at work, losing a job, and other negative life experiences. However, these temporary feelings of sadness and depression typically go away after a short period of time. Major depressive disorder lasts for longer and can lead to impairment, a disruption of daily life, harm to relationships, and problems at work or school. Although depression can cause disability in a person's life, it is treatable. The onset of depression mostly occurs in the teenage, 20s and 30s, but anyone of any age is susceptible to developing the disorder, but women are more at risk than men.
Every year, the Substance Abuse and Mental Health Services Administration (SAMHSA) conducts a survey to observe the mental health and substance abuse condition of the country. The latest data, from the Results from the 2012 National Survey on Drug Use and Health, found that almost 44 million Americans meet the criteria for some type of mental health disorder, which is 18.6 percent of the population. Almost 2 million (3.6 percent) have a co-occurring substance abuse disorder and mental health condition.
Depression is the most common type of mental illness. In the past year, about 16 million Americans (6.9 percent of the population) aged 18 and older experienced at least one major depressive episode (MDE), which is defined as having feelings of sadness or other symptoms of depression for longer than two weeks. Almost 10.5 million people (4.5 percent) had a MDE that caused severe impairment. Of the population who had serious thoughts of suicide, 26.9 percent had a major depressive episode in the past year.
Although depression is treatable, only about half of those who meet the criteria for the condition receive treatment. Around 10 million people (68 percent) received treatment for a MDE. For those who experienced severe disability, 7.6 million (73 percent) received treatment. Of those who received treatment, 10 million either saw or talked to a medical professional or used prescription medication to treat depression. Around 2.2 million only saw a medical professional, while 1 million only took drugs. The majority, 7.2 million, did both.
Depression often co-exists with substance abuse disorder. About 4.5 million people (28.5 percent) with a MDE used illicit drugs in the past year, including 2 million who abused prescription drugs, and 1.6 million (8.2 percent) who abused alcohol in the past month.
Women have a 70 percent higher chance of developing depression than men. Around 10.2 million women (8.4 percent) had depression in the past year, while only 5.8 million men (5.2 percent) did.
Different Types of Depression
In the diagnostic manual for medical professionals, known as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM 5), there are several subtypes of depression classifications. These include disruptive mood dysregulation disorder, major depressive disorder (single and recurrent episodes), persistent depressive disorder (dysthymia), premenstrual dysphoric disorders, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder. Although many of the symptoms of each of these disorders are similar, they are each a distinct condition that potentially require different treatment methods.
Major depression, also known as major depressive disorder or clinical depression, is a condition where the symptoms are so severe that they interfere with a person's ability to sleep, study, work, eat, and enjoy life. A person can have a single episode of major depression disorder, but for most people, it is a recurrent condition. Within the diagnostic criteria and symptoms, a person with major depressive disorder must meet at least 5 of the 9 main depression symptoms every day for longer than two weeks.
Persistent depressive disorder occurs when a person has a depressed mood for a period of time longer than two years. A person might also have a major depression episode followed by a period with less severe symptoms. To meet the criteria for this disorder, a person must exhibit symptoms for at least two years. These symptoms are a depressed mood, along with at least two symptoms from the following: poor appetite, overeating, insomnia or excessive sleep, fatigue or lack of energy, low self-esteem, poor concentration, feelings of hopelessness.
Although not a depression of mood like the other disorders, disruptive mood dysregulation disorder (DVDD) is also a mood disorder and falls under the depression category in the DSM-V. It involves children who have severe and recurrent temper outburst grossly out of proportion, whether in intensity or duration, to the actual situation. These must occur around three or more times every week for a period of at least one year. Between these outbursts, the children exhibit an irritable or angry mood almost every day. This occurs in at least two different settings, such as home and school, for more than a year. Typically, the onset of symptoms occurs before age 10 but not before 6, and this disorder will not be diagnosed after age 18.
Certain lifestyle phenomena cause depression to appear, especially in those already vulnerable. Some are so specific; they have their own condition, including premenstrual dysphoric disorders, substance/medication-induced depressive disorder, and depressive disorder due to another medical condition. Premenstrual dysphoric disorders include depression symptoms that coincide with a woman's menstrual cycle. Substance or medication-induced depressive disorder is depression caused by abuse or use of certain medications and substances. Some medical conditions, including long-term and fatal diseases such as cancer, can cause a person to get depressed as well, which would be depressive disorder due to another medical condition.
There are also conditions that fall under other specified depressive disorder, and unspecified depressive disorders. Some of these include psychotic depression, postpartum depression, and seasonal affective disorder (SAD). Psychotic depression occurs when a person not only exhibits severe depressive symptoms but also experiences psychosis, including delusions or hallucinations. Postpartum depression is a specific type of depression that occurs in women after giving birth. About 10 to 15 percent of women experience this condition, which is brought on by the hormonal changes and the physical changes and the new responsibilities of parenting. Seasonal affective disorder occurs during the winter months when a person does not get enough sunlight, and is often attributed in part to vitamin D deficiency. A person with SAD will find their depression better in the spring and summer months, and then return again in the fall and winter, when natural sunlight is not as long.
Symptoms of Depression
The main symptom of depression is a depressed mood that interferes with a person's daily life, work, and relationships and lasts for a significant amount of time. Although not everyone with depression will be completely debilitated, some will find it difficult to perform any task, including just getting out of bed and getting dressed. Another telltale sign of depression is no longer enjoying favorite activities. Other major symptoms include:
- Sadness, emptiness or unhappiness
- Irritability, excessive frustration, outbursts of anger, even over insignificant matters
- No longer finding pleasure or interest in normal activities
- Insomnia, change in sleeping patterns, or sleeping too much
- Fatigue, tiredness, no energy; finding it difficult to perform even small tasks
- A change in one's appetite, either reduced appetite causing weight loss or a desire to eat certain foods and gaining weight
- Anxiety, restlessness, or agitation
- A slow down of speaking, movement of the body, or thinking
- Feeling worthless, guilt, an over fixation on past failures, blaming oneself for actions for which not responsible
- Difficult concentration, thinking, remembering, or making decisions
- Suicide ideation or frequent thoughts about death
- Unexplained physical ailments, including headaches or back pain
When diagnosing major depressive disorder, clinicians look for five of the following symptoms: depressed mood, reduced interest in favorite activities, changes in appetite or weight, sleep disturbances, feeling agitated or slowed down, fatigue, feelings of worthlessness, difficult thinking or concentrating, and suicidal thoughts.
Children and adolescents with depression exhibit slightly different symptoms than adults, although many of the symptoms will be the same. Small children might exhibit symptoms such as clinginess, worry, refusing to go to school, underweight, sadness, aches and pains. For teens, the main symptoms will be feelings of self-worth, anger, poor academic performance, feeling very sensitive and misunderstood, irritability, sadness, substance abuse, eating or sleeping more than usual, self-harm, avoiding social interaction, and losing interest in activities once enjoyed.
Older adults are at risk of developing depression, especially as they become more isolated and begin to develop certain chronic age-related illnesses. However, many do not get the help they need, often because people just assume that depressed feelings are a normal part of the aging process. Other reasons for a lack of treatment in the elderly include: the symptoms are often masked by other conditions, the elderly do not seek help, or the symptoms seem slightly different or are more nuanced. In the elderly, depression symptoms include:
- Personality changes or memory difficulties
- Sleep problems, loss of appetite, fatigue, aches, loss of interest in sex, all of which cannot be explained by another medical condition or medication
- Wanting to stay at home rather than socializing
- Suicidal ideation
Causes of Depression
Depression is a complex disorder, and its exact causes are not yet determined. However, experts do know that a myriad of factors combine to lead to its development. These include environmental, genetic, biological, social, and life experiences. Researchers have found that those who have depression exhibit physical differences in the brain, but the exact causality and relationship is unsure. However, it shows that the brain shape and appearance may contribute to depression. Additionally, the neurotransmitters in the brain play a significant role. When they become out of balance for whatever reasons, a person might get depressed. Hormones have also been shown to cause or trigger depression. In addition to the hormonal changes in women due to having a baby or the menstrual cycle, thyroid problems and menopause can also cause this. People who have a family history of depression have a higher risk of developing it. Significant traumatic events can cause the development of depression, especially in those who are vulnerable.
Risk Factors for Depression
Although anyone could develop depression, there are certain risk factors that increase a person's chance of having the condition. Some personality traits increase a person's chance of developing depression, as do certain other conditions.
- Being a woman
- Having depression as a child or teenage
- A history of other mental conditions, including anxiety disorder, borderline personality disorder, or post traumatic stress disorder (PTSD)
- Substance abuse or addiction
- Isolation or having a small social network
- Personality traits including low-self esteem, overly dependent, self-critical, pessimistic
- A serious or chronic illness
- Some medications
- Experiencing a traumatic or stressful event
- Family history of depression, bipolar disorder, alcoholism or suicide
Common Conditions that Co-Occur with Depression
Depression has a high comorbidity rate with other conditions. This means that it often develops alongside, or due to, another condition, which might be a medical condition, illness, or behavioral health disorder. Several conditions commonly occur with depression, cause depression, are caused by depression, or have some other relationship with the disorder, including substance abuse, eating disorders, suicide, anxiety disorder, post traumatic stress disorder, and bipolar disorder.
Substance abuse and depression have a significant relationship, often co-occurrring, and in some people it is difficult to know which disorder developed first. Some people turn to drugs or alcohol to self-medicate depression. Over time, they build up a tolerance, so they have to consume even more alcohol or drugs. This causes the body to develop a dependency that requires special treatment to overcome the addiction. In order to fully recover from both the substance abuse or addiction and depression, the person must go through a dual diagnosis treatment program. This treats both the depression and substance abuse concurrently to reduce the risk of relapse.
People who have eating disorders also are at risk of depression. The alterations to a person's body chemistry due to too much or too little food can create changes in the hormones and brain chemistry. This can lead to depression. Additionally, eating disorders are highly associated with feelings of low-self esteem, negative self-wroth, and a poor body image. These feelings can also lead to a person feeling depressed. The guilt and shame of the disorder may also lead to a person becoming depressed.
Depression also can occur alongside other psychological conditions. The most common psychological condition to develop alongside depression is anxiety. About half of those diagnosed with depression also meet the criteria for anxiety disorder. Schizophrenia, personality disorders, and post traumatic stress disorder also have a high rate of comorbitidy.
Bipolar disorder is often misdiagnosed as depression. Many people with bipolar seek treatment during a depressive state, and neglect to talk about the manic episodes. This can be harmful, as bipolar disorder needs different treatment than depression. If bipolar is only treated as depression, a person will not get better, and may get worse.
People who suffer from a chronic illness are more at risk of developing depression as well. This is very common in those with an incurable disease, especially one that is fatal or disruptive to one's life, such as cancer. However, common illnesses such as diabetes and heart disease can also lead to depression. In these cases, a person's depression treatment will also have to include coping mechanisms for their particular illness. Persistent and chronic pain is also commonly associated with depression.
Depression and Suicide
Although depression is often linked to suicide, not everyone who is depressed will try suicide or even have suicide thoughts or tendencies. However, there is a significant relationship. Those with depression have a higher risk of turning to suicide than the normal population.
Treatment for Depression
Depression, although debilitating, is treatable. The main forms of treatment today are psychotherapy and medication. Many treatment programs utilize both for the best cure. Further research is currently being undertaken to find better treatment for depression, especially as antidepressants can have unpleasant side effects.
Some people can overcome their depression just by seeing their regular doctor or a psychologist or psychiatrist for regular psychotherapy sessions. However, when depression is severely limiting or co-exists with other conditions, especially substance abuse, people find it helpful to enter a residential treatment facility. These programs provide an intensive treatment program that allows a person to spend time to really understand the condition and the underlying or co-occurring conditions fueling it in order to regain control over life.
Psychotherapy is an essential aspect of any depression treatment program, whether a person enters a residential facility or just attends weekly therapy sessions. The most common type of therapy used is cognitive behavioral therapy. However, interpersonal therapy, dialectic behavioral therapy, acceptance and commitment therapy, and mindfulness techniques have also been shown to help.
Psychotherapy can help a person to identify the negative behavior patterns and beliefs and replace them with healthier and more positive options. It also allows people to explore the relationships and life experiences that may have contributed to depression, and develop healthy and positive relationships. It also teaches healthier coping mechanism and problem solving skills. People can learn how to adapt and adjust to crises or difficulties that exist in their life. Therapy can help people understand what contributes to the depression and how to alter the behavioral patterns in order to prevent a depressive episode. It also helps a person learn to handle stress and distress better.
Medication is a common form of treatment for depression. There are several types of antidepressants on the market, and the most commonly prescribed are selective serotonin reuptake inhibitors (SSRIs). These affect the serotonin (an important mood neurotransmitter) in order to increase a person's mood. They have fewer side effects than other medications. The most common types include fluoxetine (Prozac), paroxetine (Paxil), sertaline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro). Another common medication is serotonin and norepinephrine reuptake inhibitors (SNRIs), which also work on neurotransmitters to alter mood. These include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq). Another type of neurotransmitter medication includes norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin) is the most common form of these.
The older type of antidepressants, tricyclic medications such as imipramine (Tofranil) and nortriptyline (Pamelor) have more side effects, so their use is typically reserved until SSRIs have been tried. Monoamine oxidase inhibitors (MAOIs) have dangerous interaction with foods and medications, and have serious side effects, so they are only prescribed when nothing else has worked.
Many of the antidepressants have a risk of unpleasant side effects, including nausea, sexual dysfunction, headaches, insomnia, diarrhea, and agitation. Typically, these effects diminish after about 3 to 4 weeks. Additionally, most medications take a few weeks to actually work. Finding the right medication can take a long time, which is why many doctors are using genetic testing for treatment response. By seeing a person's genetic code, doctors can see the most likely effect of medications and find the one that should work the best, minimizing the time it takes to find a beneficial treatment regime. For some people, it takes several attempts at antidepressants before they find the one that actually works.
Some people can find help by implementing certain lifestyle changes, although these should be done in conjunction with a treatment program under the guidance of a doctor. Exercise, meditation, yoga, and a healthy diet have all been shown to help improve a person's mood, and therefore can help to treat depression. Abstaining from drugs and alcohol can also help to improve depression, as can eating or supplementing with omega-3 fatty acids. These can be done in conjunction with psychotherapy and medication to improve the efficacy of the overall treatment plan.
Because of the many side effects of antidepressants, many people have looked to alternative therapies to treat depression. Some studies have shown that acupuncture, massage therapy, relaxation techniques, music and art therapy, and spirituality can help. Certain herbs have also been shown to help. St. John's Wort is the most studied, but it can have interactions with certain medications, including birth control pills. None of these should be done without the oversight of a medical or psychological professional.