Depression

Depression can be a serious illness. Health professionals tend to use the terms 'depression', 'depressive illness' or clinical depression to refer to something very different from the common experience of feeling miserable or fed up for a short period of time.

In depression you may have feelings of extreme sadness that can last for a long time. These feelings are severe enough to interfere with your daily life, and can last for weeks or months rather than days.

Depression is common; about 15 percent of people will have a bout of major depression at some point in their lives and it is the fourth most common cause of disability worldwide. The number of people with depression is hard to estimate, because many don't get help or aren't formally diagnosed.

Most of the 4,000 suicides committed each year in England are linked to depression. On average, 15% of people with recurrent depression (repeated attacks) have an increased risk of suicide.

Women seem to be twice as likely to suffer from depression than men, although this could possibly be because men may be less likely to seek help. Depression can appear at any age and occurs in every Western country. There is some debate about whether it is seen in every culture across the world, although it now seems likely that depression is a universal human condition.

People with a family history of depression are more likely to experience depression themselves. Depression affects people in many different ways and can cause a wide variety of physical, psychological (mental) and social symptoms.

Doctors describe depression in the following three ways:

1. By how serious it is:

  • mild, in which there is some impact on your daily life
  • moderate, in which there is significant impact on your daily life
  • severe, in which activities of daily life are nearly impossible.

2. By physical symptoms: If you have depression you will probably have one or two (or maybe more) physical ('somatic') symptoms.

3. By psychotic symptoms: If you have depression you may also have psychotic symptoms, such as hallucinations or delusions. These symptoms don't affect everyone with depression. Please see the separate encyclopaedia topics on specific types of depression such as bi-polar affective disorder, and seasonal affective disorder (SAD) for further information.

Symptoms

If you are depressed you often lose interest in things that you used to enjoy. Depression commonly interferes with your work, social and family life. In addition, there are many other symptoms, which can be physical, psychological, and social.

Psychological symptoms:

  • continuous low / blue mood or sadness;
  • feelings of hopelessness and helplessness;
  • low self-esteem;
  • tearfulness;
  • feelings of guilt;
  • feeling irritable and intolerant of others;
  • lack of motivation, have little interest in and difficulty making decisions;
  • lack of enjoyment;
  • suicidal thoughts / thoughts of harming someone else;
  • feeling anxious or worried;
  • reduced sex drive.

Physical symptoms:

  • slowed movement / speech;
  • change in appetite / weight (usually decreased but sometimes increased);
  • constipation;
  • unexplained aches and pains;
  • lack of energy / lack of interest in sex; and
  • changes to the menstrual cycle (in women).

Social symptoms:

  • not performing well at work;
  • taking part in fewer social activities and avoiding contact with friends;
  • reduced hobbies and interests, and difficulties in home and family life.

Causes

Lots of different factors can trigger depression. For some people, upsetting or stressful life events such as bereavement, divorce, illness, redundancy and job or money worries can be the cause. This is often known as reactive depression - the depression is a reaction to the event. Its also called exogenous depression (exogenous is a Latin word meaning originating outside the body).

In other cases, depression doesnt have an obvious cause. This is sometimes called endogenous (meaning originating within the body).

Because depression can have many causes, its sometimes split into three broad groups; psychological, physical and social.

  • Psychological a stressful or upsetting life event causes a persistent low mood, low self-esteem and feelings of hopelessness about the future.
  • Physical or chemical - depression is caused by changes in levels of chemicals in the brain. For example, your mood can change as hormone levels go up and down. This is sometimes seen in women and is associated with the menstrual cycle, pregnancy, miscarriage, childbirth, and the menopause.
  • Social understanding doing fewer activities or having fewer interests can both cause depression and happen because of depression.

People who have a family history of depression also seem more likely to get depression themselves.
Quite often, depression can be triggered by more than one of these factors, and they can influence and affect each other in complicated ways.

Other frequent causes of depression include drinking excess alcohol and using street drugs such as cannabis and cocaine. Taking some prescribed medication e.g. propranolol can occasionally cause depression.

Diagnosis

If you think you have depression you should visit your GP. Your GP may do a physical check and do some blood or urine tests to rule out other conditions.

There are no clinical tests for depression so detailed interviews and questionnaires are used in the diagnosis.

There are many different questionnaires used to measure depression. However two classifications of mental illness are most widely used. The first, developed by the American Psychiatric Association, is called the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The second, developed by the World Health Organisation, is called the International Classification of Diseases - Part 10 (ICD10).

Using one of these guidelines, it is usually possible for your GP to diagnose depression, decide which type of depression you are experiencing and to rule out another mental conditions.

Treatment

Treatment for depression usually involves a combination of drug and psychological therapies.

Mild depression:

If you are diagnosed with mild depression, but your GP thinks you'll improve, or you don't want treatment at the moment, then you should have another assessment in two weeks time to monitor your progress. This is known as watchful waiting.

If you have mild depression, antidepressants aren't usually recommended as a first treatment.

Exercise seems to help some people with depression. Your GP may refer you to an exercise scheme with a qualified fitness trainer, while watchful waiting.

Talking through your feelings may also be helpful for mild depression. You may wish to talk to a friend or relative, or your GP may suggest a local self-help group. Your GP may also recommend self-help reading materials and computerised cognitive behaviour therapy (CBT). (See below)

If your depression is mild but you have a past history of depression your GP may however suggest that you also start on a course of antidepressants (see section on medicines).

Chronic mild depression (present for 2 years plus) is called dysthymia. This is more likely in people over 55 years and can be difficult to treat. If you are diagnosed with dysthymia your GP may again suggest that you also start on a course of antidepressants.

Moderate depression:

If your mild depression isn't improving or you have moderate depression, your GP may recommend a talking treatment or prescribe an antidepressant (see section on medicines).

Talking treatments

Cognitive behavioural therapy (CBT), problem- solving therapy, and counselling are examples of talking treatments. You normally have a fixed number of sessions - usually 6-8 sessions over 10-12 weeks. Some GP practices have counsellors specifically to help patients with depression.

  • Cognitive behavioural therapy (CBT) is based on the principle that the way we feel is partly dependent on the way we think about things. It teaches you to behave in ways that challenge negative thoughts - for example being active to challenge feelings of hopelessness.
  • Interpersonal therapy (IPT) focuses on your relationships with other people and on problems such as difficulties in communication, or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT but more research is needed.
  • Counselling is a form of therapy that helps you to think about the problems you're experiencing in your life, in order to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but don't tell you what to do.

Research has shown that antidepressants and talking therapies are equally effective in treating mild or moderate depression but having the two types of treatment together does not seem to offer any extra benefits.

Your GP may therefore alternatively suggest that you start a course of antidepressants. Your preference and the availability of talking therapies will be taken into account when deciding which treatment is most appropriate for you.

Severe depression:

If you have severe depression, your GP may recommend that you take an antidepressant together with talking therapy.

A combination of an antidepressant and CBT usually works better than having just one of these treatments in severe depression.

A combination of an antidepressant and CBT usually works better than having just one of these treatments in severe depression.

You may be referred to a mental health team if your depression is severe, or doesn't respond to treatment from your GP. These teams are usually made up of psychologists, psychiatrists, specialist nurses, and occupational therapists. They often provide intensive specialist talking treatments such as cognitive therapy or psychotherapy.

Sometimes other treatments such as specialist medicines (see section on medicines) or Electro convulsive therapy (ECT) may be advised if you have severe depression. Electro convulsive therapy (ECT) works for severe depression, but is only used when antidepressants and other treatments haven't worked. If you are given ECT you are first given an anaesthetic and drugs to relax your muscles. You will then receive an electrical 'shock' to the brain, through electrodes placed on your head. You may be given a series of ECT sessions. For most people the treatment works well in relieving severe depression, but the effect may not be permanent. Some people experience unpleasant side effects, including memory problems.

Complications

About half of the people who have a first episode of depression will have another episode within 10 years. The risk of further bouts of depression is higher than in someone who has never been depressed.

Mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide.

Prevention

To deal with depression and help to prevent repeated bouts of depression, you should:

  • take your medicines regularly as directed, without skipping any days;
  • discuss reducing or stopping medication with your GP, BEFORE you make any changes;
  • gradually try to increase activities you enjoy;
  • avoid smoking, illegal drugs and alcohol. These may appear to make you feel better in the short-term but can make you feel worse in the long term;
  • use a problem solving approach to deal with stresses and worries;
  • try to identify negative thoughts and change them to positive thoughts;
  • assess your symptoms regularly and consult your doctor and/or counsellor if problems arise;
  • try to exercise more. Exercise can trigger the release of the brain chemical serotonin, which boosts your mood. A simple programme of aerobic or non-aerobic exercise improves depression in some people, even when medication hasnt been effective;
  • learn how to relax using relaxation exercises and tapes;
  • practice yoga, meditation or have a massage to help relieve tension and anxiety;
  • eat a well-balanced diet. Try not to eat junk food, as this can make you feel worse. Healthy eating may help overcome some symptoms;
  • and join a self-help group and discuss your feelings and concerns. This can help you to feel less isolated.

Side effects

Drug treatments for depression are associated with a number of side effects. Generally, newer drugs such as SSRIs have fewer and less severe side effects than older drug therapies.

Psychological therapies have few, if any side effects. Some other therapies do have some side effects. For example, ECT can cause short-term headaches, memory problems, nausea and muscle aches.

The complementary therapy St Johns Wort can result in feeling sick, causing dizziness and a dry mouth.

The information shown here is Crown copyright and has been reproduced with the permission of NHS Direct. Last updated June 2007.

Depression in later life

There are a number of challenges that exist as we get older. Because of this, some people may see low mood as a natural part of ageing. This is not the case. There are many people who have good mental health in later life. If you are feeling low, there are many things that can help.

Some people may not recognise they are having problems with depression. Symptoms such as aches and pains, agitation and apathy, and problems with memory can all be symptoms of depression. Low mood may not be the most noticeable symptom. It is important to try to get help for depression.