Depression

Major depression is a period of sadness, irritability, or low motivation that occurs with other symptoms that lasts at least two weeks and fulfills other diagnostic criteria.

Depressive disorders are mood disorders that have been with mankind since the beginning of recorded history. What are the symptoms and impaired functions that experts can agree make up a depressive illness? Although experts sometimes dispute these issues, most agree on the following:

1. A depressive disorder is a syndrome (a group of symptoms) characterized by sad and/or irritable mood exceeding normal sadness or grief. More specifically, the sadness of depression is characterized by a greater intensity and duration and by more severe symptoms and functional problems than is normal.
2. Depressive signs and symptoms not only include negative thoughts, moods, and behaviors but also specific changes in bodily functions (for example, excessive crying spells, body aches, low energy or libido, as well as problems with eating, weight, or sleeping). Neurovegetative signs are the changes in functioning associated with clinical depression. This means that the nervous system changes in the brain are thought to cause many physical symptoms that result in a decreased or increased activity level and other problems with functioning.
3. People with certain depressive disorders, especially bipolar depression (manic depression), seem to have an inherited vulnerability to this condition.
4. Depressive illnesses are a huge public health problem, due to their affecting millions of people. Facts about depression include that about 10% of adults experience some kind of depressive disorder. Postpartum depression is the most common mental health disorder to afflict women after childbirth.
5. Depression is usually first identified in a primary care setting, not in a mental health professional's office. Moreover, it often assumes various disguises, which causes depression to be frequently underdiagnosed.
6. In spite of clear research evidence and clinical guidelines regarding treatment, depression is often undertreated. Hopefully, this situation can change for the better.
7. For full recovery from a mood disorder, regardless of whether there is a precipitating factor or it seems to come out of the blue, treatment with medication, phototherapy, electroconvulsive therapy (ECT), and/or transcranial magnetic stimulation, (see discussion below), as well as psychotherapy and/or participation in a support group, is necessary.

• It is a weakness rather than an illness.
• If the depression sufferer just tries hard enough, it will go away without treatment.
• If you ignore depression in yourself or a loved one, it will go away.
• Highly intelligent or highly accomplished people do not get depressed.
• Poor people do not get depressed.
• Minorities do not get depressed.
• People with developmental disabilities do not get depressed.
• People with depression are "crazy."
• Depression does not really exist.
• Children, teens, the elderly, or men do not get depressed.
• Depression cannot look like (present as) irritability.
• The symptoms of depression are the same for everyone who gets the illness.
• People who tell someone they are thinking about committing suicide are only trying to get attention and would never do it, especially if they have talked about it before.
• People with depression cannot have another mental or medical condition at the same time.
• Psychiatric medications are all addicting.
• Psychiatric medications do not work; any improvement felt is in the sufferer's imagination.
• Psychiatric medications are never necessary to treat depression.
• Medication is the only effective treatment for depression. People should never give children and teens antidepressant medication.

Depressive disorders are mood disorders that come in different forms, just as do other illnesses, such as heart disease and diabetes. However, remember that within each of these types, there are variations in the number, timing, severity, and persistence of symptoms. There are sometimes also differences in how individuals express and/or experience depression based on age, gender, and culture.

Major depressive disorder

Major depression, also often referred to as unipolar depression, is characterized by a combination of symptoms that lasts for at least two weeks in a row, including depressed and/or irritable mood (see symptom list), that interferes with the ability to work, sleep, eat, and enjoy once-pleasurable activities. Difficulties in sleeping or eating can take the form of excessive or insufficient of either behavior. Disabling episodes of depression can occur once, twice, or several times in a lifetime.

Persistent depressive disorder (dysthymia)

Persistent depressive disorder, formerly referred to as dysthymia, is a less severe but usually more long-lasting type of depression (dysphoric) compared to major depression. It involves long-term (chronic) symptoms that do not disable but prevent the affected person from functioning at "full steam" or from feeling good. Sometimes, people with persistent depressive disorder also experience episodes of major depression. Double-depression is the name for this combination of the two types of depression.

Bipolar disorder (manic depression)

Another type of depression is bipolar disorder, which encompasses a group of mood disorders formerly called manic-depressive illness or manic depression. These conditions often show a particular pattern of inheritance. Not nearly as common as the other types of depressive illnesses, bipolar disorders involve cycles of mood that include at least one episode of mania or hypomania and may include episodes of depression, as well. Bipolar disorders are often chronic and recurring. Sometimes, the mood switches are dramatic and rapid, but most often they are gradual, in that they usually take place over several days, weeks, or longer.

When in the depressed cycle, the person can experience any or all of the symptoms of a depressive condition. When in the manic cycle, any or all of the symptoms listed later in this article under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, indiscriminate or otherwise unsafe sexual practices or unwise business or financial decisions may be made when an individual is in a manic phase.

Bipolar II disorder is a significant variant of the bipolar disorders. (The usual form of bipolar disorder is referred to as bipolar I disorder.) Bipolar II disorder is a syndrome in which the affected person has repeated depressive episodes punctuated by hypomania (mini-highs). These euphoric states in bipolar II do not completely meet the criteria for the full manic episodes that occur in bipolar I.

Postpartum depression (PPD)

Postpartum depression (PPD) is a condition that describes a range of physical and emotional changes that many mothers can have after having a baby. PPD can be treated with medication and counseling. Talk with your health care provider right away if you think you have PPD that is interfering with your ability to function in any way.

There are three types of depression or mental changes women can have after giving birth:

• The so-called "baby blues" happen in many women in the days right after childbirth. A new mother can have sudden mood swings, such as feeling very happy and then feeling very sad or angry. She may cry for no reason and can feel impatient, irritable, restless, anxious, lonely, and sad.
• Postpartum depression (PPD) can happen a few days or even months after childbirth. A woman can have feelings similar to the baby blues -- sadness, despair, anxiety, irritability -- but she feels them much more strongly than she would with the baby blues. PPD often keeps a woman from doing the things she needs to do every day. While PPD is a serious condition, it can be treated with medication and counseling.
• Postpartum psychosis is a very serious mental illness that can affect new mothers. This illness can happen quickly, often within the first three months after childbirth. Women can experience psychotic depression, in that the depression causes them to lose touch with reality, have auditory hallucinations (hearing things that aren't actually happening, like a person talking when there is no one there), and delusions (interpreting things completely differently from what they are in reality). Visual hallucinations (seeing things that aren't there) are less common.

Symptoms of depression and mania

Not everyone who is depressed or manic experiences every symptom. Some people suffer from a few symptoms and some many symptoms. The severity of symptoms also varies with individuals. Less severe symptoms that precede the more debilitating symptoms are often called warning signs.

Depressive symptoms of major depression or manic depression

• Persistent feelings of sadness, anxiety, anger, irritability, discontent, or "emptiness"
• Feelings of hopelessness or pessimism
• Feelings of worthlessness, helplessness, or excessive guilt
• Loss of interest or inability to feel pleasure in hobbies and activities that individuals once enjoyed, including sex
• Apathy/lack of motivation
• Social isolation, meaning the sufferer avoids interactions with family or friends
• Sleep changes, like insomnia, early morning awakening, restless sleep, excess sleepiness, or oversleeping
• Appetite changes, like loss of appetite and/or weight, or excessive hunger, overeating, and/or weight gain
• Fatigue/tiredness, decreased energy levels, slowness in activity or thought
• Crying spells
• Thoughts of death or suicide, suicide attempts
• Restlessness, agitation, irritability
• Inability to concentrate, remember things, make decisions, or to handle responsibilities
• Persistent physical symptoms that do not respond to treatment, such as repeated headaches, digestive disorders, and/or chronic pain

Mania symptoms of manic depression

• Inappropriate or excessive elation/expansive mood
• Inappropriate or excessive irritability or anger
• Severe insomnia or decreased need to sleep
• Grandiose notions, like having a belief in special powers or importance
• Increased talking speed and/or volume
• Disconnected/tangential thoughts or speech
• Racing thoughts
• Severely increased sexual desire and/or activity
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

In addition to becoming more irritable, teens might lose interest in activities they formerly enjoyed, experience a change in their weight, and start abusing substances. They may also take more risks, show less concern for their safety, and they are more likely to complete suicide than their younger counterparts when depressed. Generally, acne increases the risk of teen depression.

Since babies, toddlers, and preschool children are usually unable to express their feelings in words, they tend to show sadness in their behaviors. For example, they may become withdrawn, resume old, younger behaviors (regress), or fail to thrive. School age children might regress in their school performance, develop physical complaints, anxiety, or irritability. Interestingly, some children may try more, sometimes even excessively, to please others when depressed as a way of compensating for their low self-esteem. Therefore, their good grades and apparently good relationships with others may make depression harder to recognize.

Children and adolescents with depression may also experience the classic symptoms as adults as described above, but they may exhibit other symptoms instead of or in addition to those symptoms, including the following:

• Poor school performance
• Persistent boredom or irritability
• Frequent complaints of physical problems such as headaches and stomachaches
• Some of the classic "adult" symptoms of depression may also be more or less obvious during childhood compared to the actual emotions of sadness, such as a change in eating or sleeping patterns. (Has the child or teen lost or gained weight or failed to gain appropriate weight for their age in recent weeks or months? Does he or she seem more tired than usual? Does the minor have a sense of low self-worth?)

Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder.

• Genetics: Some types of depression run in families, indicating an inheritable biological vulnerability to depression. This seems to be the case, especially with bipolar disorder. Major depression also seems to occur in generation after generation in some families, although not as strongly as in bipolar I or II. Indeed, major depression can also occur in people who have no family history of depression.
• External stressors: An external event often seems to initiate an episode of depression. Thus, a serious loss, chronic illness, difficult relationship, exposure to abuse, neglect or community violence, financial problem, or any negative life events or unwelcome changes in life patterns can trigger a depressive episode and chronic exposure to such negative factors can result in persistent depression.
• Ethnic and socioeconomic status: Stressors that contribute to the development of depression sometimes affect some groups more than others. For example, minority groups who more often feel impacted by discrimination are disproportionately represented. Socioeconomically disadvantaged groups have higher rates of depression compared to their advantaged counterparts. Immigrants to the United States may be more vulnerable to developing depression, particularly when isolated by language.
• Drug use: There are also some drugs whose effects can include depression (these include alcohol, narcotics, and marijuana) and those for whom depression can be a symptom of withdrawal from the substance (including caffeine, cocaine, or amphetamines).
• Medications: Certain medications used for a variety of medical conditions are more likely than others to cause depression as a side effect. Specifically, some medications that treat high blood pressure, cancer, seizures, extreme pain, and to achieve contraception can result in depression. Even some psychiatric medications, like some sleep aids and medications to treat alcoholism and anxiety, can contribute to the development of depression.
• Other mental health conditions: Many mental health conditions or developmental disabilities are associated with depression, as well. Individuals with anxiety, attention deficit hyperactivity disorder (ADHD), substance abuse, and developmental disabilities may be more vulnerable to developing depression.
• Neurotransmitters: The depressive disorders appear to be associated with altered brain serotonin and norepinephrine systems. Both of these neurochemicals may be lower in depressed people. Please note that depression is "associated with" instead of "caused by" abnormalities of these neurochemicals because we really don't know whether low levels of neurochemicals in the brain cause depression or whether depression causes low levels of neurochemicals in the brain.
• Maternal-fetal stress: The presence of maternal-fetal stress is another risk factor for depression. It seems that maternal stress during pregnancy can increase the chance that the child will be prone to depression as an adult, particularly if there is a genetic vulnerability. Researchers believe that the mother's circulating stress hormones can influence the development of the fetus' brain during pregnancy. This altered fetal brain development occurs in ways that predispose the child to the risk of depression as an adult.
• Gender: Women and men have similar risk factors for depression for the most part.
  • Women who have been the victim of physical, emotional, or sexual abuse, either as a child or perpetrated by a romantic partner are vulnerable to developing a depressive disorder. Women are twice as likely to become depressed as men.
  • Men appear to be particularly sensitive to the depressive effects of unemployment, divorce, low socioeconomic status, and having few good ways to cope with stress. Men who engage in sex with other men seem to be particularly vulnerable to depression when they have no domestic partner, do not identify themselves as homosexual, or have been the victim of multiple episodes of antigay violence.
• Psychological factors: These also contribute to a person's vulnerability to depression. Thus, persistent deprivation in infancy, physical or sexual abuse, exposure to community violence, clusters of certain personality traits, and inadequate ways of coping (maladaptive coping mechanisms) all can increase the frequency and severity of depressive disorders, with or without inherited vulnerability.
• Childhood stress: People exposed to numerous and/or severe stressors as young children may develop changes in their brain structure that may make them prone to developing depression during adulthood.

Depression is a complicated disorder with numerous causes. Several studies have identified a link between low folate levels and depression. Folic acid is required for the formation of the neurotransmitters serotonin, norepinephrine, and dopamine, which are known to be deficient in depression.

According to the literature,depression has been associated with folate deficiency, and patients with low folate are less likely to respond to treatment and more likely to relapse.

Some individuals benefit from folate supplementation although the concept is a bit complicated.

• Folic acid does not, by itself, cure depression. Before the brain can produce enough serotonin, norepinephrine, and dopamine to treat depression, it must convert folic acid into L-methylfolate.
• However, some people cannot convert folic acid to L-methylfolate, making folic acid supplementation ineffective for them.
• The methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism, which is relatively frequent in people with depression, causes this processing deficit.
• Those people must avoid using folate and instead, supplement L-methylfolate.

Of course, this does not imply that having low folate levels will always result in depression, or having normal folate levels will avoid depression.

People who wonder if they should talk to their health professional about whether or not they have depression might consider taking a depression quiz or self-test, which asks questions about depressive symptoms that are included in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), the accepted diagnostic reference for mental illnesses. In thinking about when to seek medical advice about depression, the sufferer can benefit from considering if the sadness lasts more than two weeks or so or if the way they are feeling significantly interferes with their ability to function at home, school, work, or in their relationships with others. The first step to getting appropriate treatment is accurate diagnosis, which requires a complete physical and psychological evaluation to determine whether the person may have a depressive illness, and if so, what type.

A thorough diagnostic evaluation includes a complete history of the patient's symptoms:

1. When did the symptoms start and under what circumstances/stressors?
2. How long have symptoms lasted?
3. How severe are the symptoms?
4. Have the symptoms occurred before, and if so, were they treated, what treatment was received, and was it effective?

The doctor usually asks about alcohol and drug use and whether the patient has had thoughts about death or suicide. Further, the history often includes questions about whether other family members have had a depressive illness, and if treated, what treatments they received and which were effective. Professionals are becoming increasingly aware of the importance of exploring potential cultural differences in how people with depression experience, understand, and express depression in order to appropriately assess and treat this condition.

A diagnostic evaluation also includes a mental-status examination to determine if the patient's speech, thought pattern, or memory has been affected, as often happens in the case of a depressive or manic-depressive illness. As of today, there is no laboratory test, blood test, or X-ray that can diagnose a mental disorder.

Regardless of the medication that treats depression, practitioners have become more aware that both genders, each age group, and different ethnic groups may have different responses and have different risks for medication side effects than others. Also, while there are certainly treatment methods that have been determined to be effective across populations, given the individual variability of response to treatment, there should not be a one-size-fits-all approach to treatment.

Antidepressant medications

• Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of the neurochemical serotonin in the brain. (Remember that brain serotonin levels often are low in depression.) As their name implies, the SSRIs work by selectively inhibiting (blocking) serotonin reuptake in the brain. SSRIs have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Patients generally tolerate SSRIs well, and side effects are usually mild. The most common side effects are nausea and other stomach upset, diarrhea, agitation, insomnia, and headache.
• Dual-action antidepressants have particularly robust effects on both the norepinephrine and serotonin systems. These medications seem to be very promising, especially for the more severe and chronic cases of depression.
• Atypical antidepressants work in a variety of ways. They increase the level of certain neurochemicals in the brain synapses (between nerves, where nerves communicate with each other).
• Mood stabilizers are used to treat bipolar depression, usually in combination with other antidepressants.
• Monoamine oxidase inhibitors (MAOIs) are the earliest developed antidepressants and they elevate the levels of neurochemicals in the brain synapses by inhibiting monoamine oxidase. Monoamine oxidase is the main enzyme that breaks down neurochemicals, such as norepinephrine. When monoamine oxidase is inhibited, the norepinephrine is not broken down and, therefore, the amount of norepinephrine in the brain is increased. MAOIs also impair the ability to break down tyramine, a substance found in aged cheese, wines, most nuts, chocolate, certain processed meats, and some other foods. Tyramine, like norepinephrine, can elevate blood pressure. Therefore, the consumption of tyramine-containing foods by a patient taking an MAOI drug can cause elevated blood levels of tyramine and dangerously high blood pressure.
• Tricyclic antidepressants (TCAs) work mainly by increasing the level of norepinephrine in the brain synapses, although they also may affect serotonin levels. Doctors often use TCAs to treat moderate to severe depression. TCAs are safe and generally well tolerated when properly prescribed and administered. However, if taken in overdose, TCAs can cause life-threatening heart-rhythm disturbances.
• Stimulants, which are primarily used to treat attention deficit hyperactivity disorder (ADHD), are also used for the treatment of depression that is resistant to other medications. The stimulants are most commonly used along with other antidepressants or other medications, such as mood stabilizers, antipsychotics, or even thyroid hormone.

Patients gradually should taper antidepressants and should not be abruptly discontinued. Abruptly stopping an antidepressant in some patients can cause discontinuation syndrome. Abruptly stopping MAOIs can lead to irritability, agitation, and delirium. Similarly, abruptly stopping a TCA can cause agitation, irritability, and abnormal heart rhythms.

Phototherapy

Phototherapy, a particularly effective treatment for seasonal affective disorder, entails the individual with depression being exposed to cool-white florescent light at a strength of 10,000 lux for half an hour every day.

Electroconvulsive therapy (ECT)

With the ECT procedure, a brain stimulation therapy, a physician passes an electric current through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or have not responded to a number of antidepressants, have severe depression, and/or are at a high risk for suicide. ECT often is effective in cases where trials of a number of antidepressant medications do not provide sufficient relief of symptoms. This procedure probably works, as previously mentioned, by a massive neurochemical release in the brain due to the controlled seizure.

Transcranial magnetic stimulation (TMS)

Another brain stimulation therapy, transcranial magnetic stimulation (TMS) involves a physician passing an electrical current through an insulated coil that is placed on the surface of the depression sufferer's scalp. That induces a brief magnetic field that can change the electrical flow of the brain that is effective in easing symptoms of depression or anxiety. TMS does not require anesthesia; doctors perform TMS for a few minutes per session, five times per week over the course of four to six weeks. Side effects are usually mild and fade quickly, including scalp discomfort or headaches. Transcranial magnetic stimulation is effective in alleviating depression or anxiety in people who did not respond to psychiatric medication.

Psychotherapies

Many forms of psychotherapy are effective at helping depressed individuals, including some short-term (10-20 weeks) therapies. Talking therapies (psychotherapies) help patients gain insight into their problems and resolve them through verbal give-and-take with the therapist. Behavioral therapists help patients learn how to obtain more satisfaction and rewards through their own actions. These therapists conduct behavior therapy to help patients to unlearn the behavioral patterns that may contribute to their depression. Interpersonal and cognitive/behavioral therapies are two of the short-term psychotherapies that research has shown to be helpful for some forms of depression. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression.

• Cognitive/behavioral therapy is a framework that helps patients change the negative styles of thinking and behaving that are often associated with depression.
• Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy that tends to focus on intensive, simultaneous acceptance of the depression sufferer's abilities, while motivating emotionally healthy changes using a highly structured approach. This form of therapy treats severely or chronically depressed people.
• Psychodynamic therapies sometimes treat depression. They focus on resolving the patient's internal psychological conflicts rooted in childhood. Long-term psychodynamic therapies are particularly important if there seems to be a lifelong history and pattern of inadequate ways of coping (maladaptive coping mechanisms) by using negative or self-injurious behavior.

Alternative medicine approaches to treatment

The future is very bright for the treatment of depression. In response to the customs and practices of their patients from a variety of cultures, physicians are becoming more sensitized to and knowledgeable about natural remedies. Vitamins and other nutritional supplements like vitamin D, folate, and vitamin B12 may be useful in alleviating mild depression when used alone or more severe degrees of depression when used in combination with an antidepressant medication. Another intervention from alternative medicine is St. John's wort (Hypericum perforatum). This herbal remedy may be helpful for some individuals who suffer from mild depression. However, St. John's wort being an herbal remedy is no guarantee against developing complications. For example, its chemical similarity to many antidepressants disqualifies it from being given to people who are taking those medications.

In general, the severe depressive illnesses, particularly those that are recurrent, will require antidepressant medications, phototherapy for winter seasonal depression (or ECT or TMS in severe cases) along with psychotherapy for the best outcome. If a person suffers one major depressive episode, he or she has up to about a 75% chance of a second episode. If the individual suffers two major depressive episodes, the chance of a third episode is about 80%. If the person suffers three episodes, the likelihood of a fourth episode is 90%-95%. Therefore, after a first depressive episode, it may make sense for the patient to come off medication gradually. However, after a second and certainly after a third episode, most clinicians will have a patient remain on a maintenance dosage of the medication for an extended period of years, if not permanently.

Patience is required because the treatment of depression takes time. Sometimes, the doctor will need to try a variety of antidepressants before finding the medication or combination of medications that is most effective for the patient. Sometimes, it's necessary to increase the dosage to be effective or decrease the dosage to alleviate medication side effects.

In choosing an antidepressant, the doctor will take into account the patient's specific symptoms of depression, as well as his or her age, other medical conditions, and medication side effects. Of particular importance is that children and adolescents continue to use antidepressant medication with caution because of uncommon instances in which minors become acutely worse instead of better while receiving this treatment.

Doctors often use one of the SSRIs initially because of their lower severity of side effects compared to the other classes of antidepressants. It's possible to further minimize side effects of SSRI medications by starting them at low doses and gradually increasing the doses to achieve full therapeutic effects. For those patients who do not respond after taking a SSRI at full doses for six to eight weeks, doctors often switch to a different SSRI or another class of antidepressants. For patients whose depression failed to respond to full doses of one or two SSRIs or whom could not tolerate those medications, doctors will usually then try medications from another class of antidepressants. Some doctors believe that antidepressants with dual action (action on both serotonin and norepinephrine) may be effective in treating patients with severe depression that is treatment resistant.

Increasingly, doctors may use a combination of antidepressants from different classes or add a medication from a completely different chemical class that are thought to enhance the effectiveness of antidepressant medication more rapidly than adding or switching to a second antidepressant. Also, new types of antidepressants are constantly being developed, and one of these may be the best for a particular patient.

If the patient is taking MAOIs, he or she must avoid certain aged, fermented, or pickled foods, like many wines, processed meats, and cheeses. The patient should obtain a complete list of prohibited foods from the doctor and keep it available at all times. The other types of antidepressants require no food restrictions. It is also important to note that some over-the-counter cold and cough medicines can also cause problems when taken with MAOIs.

People should try to avoid mixing medications of any kind (prescribed, over the counter, or borrowed) without consulting their doctor. Patients should inform their dentist or any other medical specialist who prescribes a drug that he or she is taking antidepressants. Some medications that are harmless when taken alone can cause severe and dangerous side effects when taken with other medications. This may also be the case for individuals taking supplements or herbal remedies. Some addictive substances, like alcohol (including wine, beer, and liquor), tranquilizers, narcotics or marijuana, reduce the effectiveness of antidepressants and can cause mental health and/or physical symptoms. Patients should avoid these. These and other drugs can be dangerous when the person's body is either intoxicated with or withdrawing from their effects due to increasing the risk of seizure or heart problems in combination with antidepressants medications.

Even though clinical depression tends to occur in episodes, most people who experience one such episode will eventually have another one. Also, it seems that any subsequent episodes of depression are more easily triggered than the first one. However, most depression sufferers recover from the episode. In fact, individuals who have mild depression and receive treatment with medication tend to respond equally as well to sugar pill (placebo). Those with more severe depression seem to be less likely to get better when taking placebo versus taking antidepressant medication. Other encouraging information is that research shows that even people from teenage through adulthood who do not improve when treated with a first medication trial can improve when switched to another medication or given another medication in addition to psychotherapy. For individuals who experience thoughts of suicide, preventing access to firearms and other highly lethal means of committing suicide are important ways to improve their safety and that of those around them.

Depression can have a significant impact on the structure and function of many parts of the brain. This can result in many negative consequences. For example, people with severe depression are at higher risk of suffering from anxiety, chronic depression, other emotional issues, or having more medical problems or chronic pain. The trouble thinking (cognitive problems) that depression sufferers may experience can persist even after the illness resolves. People with a chronic illness, such as diabetes and heart disease, who also have depression tend to have worse outcome of their medical illness.

Programs that use mental health professionals to teach thinking skills (cognitive techniques) that assist in coping with stress seem to be effective in preventing depression. Key aspects in the prevention of postpartum depression include helping new mothers decrease those specific aspects of their lives that may contribute to depression, like having little social support and poor adjustment to their marriage or other domestic union. Engaging in religious or spiritual practices can often prevent depression, thought to be the result of decreasing stress, increasing a sense of hope, and providing a sense of community. On the other hand, people who feel they are unable to live up to the standards set by their family, societal, religious, or spiritual practices may feel a sense of guilt that becomes a risk factor for depression.

Depressive disorders can make those afflicted feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depressive illness and typically do not accurately reflect the actual situation. Negative thinking fades as treatment begins to take effect. In the meantime, the following are helpful tips for how to fight depression:

• Eat healthy foods and stay hydrated. The frequent lack of adequate nutrients, including water, and presence of excessive fats, sugars, and sodium in fast foods can further sap the energy of depression sufferers.
• Many may find that folate and vitamin D food supplements help coping with depression.
• Make time to get enough rest to promote improvement in your mood.
• Express your feelings, either to friends, in a journal, or using art to help release some negative feelings.
• Do not set difficult goals for yourself or take on a great deal of responsibility while dealing with depression.
• Break large tasks into small ones, set some priorities, and do what you can when you can.
• Do not expect too much from yourself too soon as this will only increase feelings of failure.
• Try to be with other people, which is usually better than being alone.
• Participate in activities that may make you feel better.
• You might try exercising, going to a movie or a ball game, or participating in religious or social activities.
• Don't rush or overdo it. Don't get upset if you do not feel "cured" right away. Feeling better takes time.
• Do not make major life decisions, such as changing jobs or getting married or divorced until your depression has improved without consulting others who know you well. These people often can have a more objective view of your situation.
• Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression responds to treatment.
• Plan how you would get help for yourself in an emergency, like calling friends, family, your physical or mental health professional, a local emergency room, or mental health crisis center if you were to develop thoughts of harming yourself or someone else.
• Limit your access to things that could hurt yourself or others (for example, do not keep excess medication of any kind, firearms, or other weapons in the home).

Family and friends can help! Since depression can make the affected person feel exhausted and helpless, he or she will want and probably need help from others. However, people who have never had a depressive disorder may not fully understand its effects. Although unintentional, friends and loved ones may unknowingly say and do things that may be hurtful to the depressed person.

• Encourage appropriate diagnosis: The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. Encourage the individual to stay with treatment until symptoms begin to go away (usually several weeks) or to seek different treatment if no improvement occurs.
• Go to the doctor: Make an appointment and accompany the depressed person to the doctor. Monitor whether the depressed person is taking medication for several months after symptoms have improved. Always report a worsening depression to the patient's physician or therapist.
• Offer emotional support: This support involves providing understanding, patience, affection, and encouragement to the depression sufferer. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always take them seriously and report them to the depressed person's therapist.
• Get them out: Invite the depressed person for walks, outings, and to the movies and other activities. Be gently insistent if the depressed individual refuses your invitation. Encourage participation in activities that once gave pleasure, such as hobbies, sports, or religious or cultural activities. However, do not push the depressed person to undertake too much too soon. The depressed person needs company and diversion, but too many demands can increase feelings of failure and exhaustion.
• Don't accuse or pressure them: Do not accuse the depressed person of faking illness or of laziness. Do not expect him or her "to snap out of it."

Eventually, with treatment, most depressed people do get better. Keep that in mind. Moreover, keep reassuring the depressed person that, with time and help, it is highly likely that he or she will feel better.

For further information about depression, please visit the following sites:
Suicide Awareness Voices of Education (SAVE)
http://www.save.org/

APA: Women and Depression (American Psychological Association)
http://www.apa.org/pi/women/
programs/depression/index.aspx

For additional information and help, you can write or call the following organizations:

D/ART/Public Inquiries; National Institute of Mental Health
Room 15C-05
5600 Fishers Lane
Rockville, MD 20857

National Foundation for Depressive Illness
20 Charles Street
New York, NY 10014

National Depressive and Manic Depressive Association
730 N. Franklin, Suite 501
Chicago, IL 60601
Phone: 800-826-3632
Phone: 312-642-0049
Fax: 312-642-72433
http://www.ndmda.org/

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314-2971
800-969-NMHA (6642)
http://www.nmha.org/

National Alliance for the Mentally Ill
2101 Wilson Boulevard
Suite 302
Arlington, VA 22201
HelpLine: 800-950-NAMI [6264]
http://www.nami.org/

National Alliance for Research on Schizophrenia and Affective Disorders (NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021 USA
Infoline: 800-829-8289
http://www.narsad.org/

National Suicide Prevention Lifeline
800-273-8255

Substance Abuse and Mental Health Services Administration (SAMHSA)
5600 Fishers Lane
Rockville, MD 20857
http://www.samhsa.gov

Suicide.org (for a suicide hotline near you)

Surgeon General's Report on Mental Illness
To receive a copy of this report, write or call:
Mental Health
Pueblo, Co 81009
800-789-2647

The National Institute of Mental Health (NIMH) for the Depression Awareness, Recognition, and Treatment (DART) program furnished a portion of the foregoing information.