Managing depression

Depression is not just feeling sad or "fed up"—and it's certainly not a character flaw. Depression, sometimes called clinical depression or major depressive disorder, is a common, serious mood disorder that affects how people feel, think and are able to function in their day-to-day life.

Depression affects people in different ways and can cause a wide variety of symptoms. The Diagnostic and Statistical Manual of Mental Disorders classifies depressive disorders as mild, moderate or severe (major), based on the number, type and severity of symptoms, as well as the individual’s ability to function.

Signs of depression include:

• Lasting feelings of unhappiness and hopelessness
• Loss of interest in things or activities that were previously enjoyable 
• Feeling tired or sleeping all of the time or sleeping poorly
• Aches and pains
• Loss of appetite
• Loss of sex drive 
• Trouble concentrating
• Restlessness or irritability
• Memory lapses or trouble making decisions
• Thoughts of death or suicide, or attempts at suicide 

People with chronic depression may experience persistent physical symptoms, such as headaches, stomach problems or pain that do not respond to treatment or have no other identifiable causes. For a healthcare provider to diagnose someone with depression, they must have symptoms for at least two weeks.

Depression is caused by a complex combination of genetic, biological, environmental and psychological factors. It can occur on its own or it can happen with other serious medical illnesses, such as cancer or heart disease. In these cases, depression can worsen these diseases. Sometimes medications may cause side effects that contribute to depression. In addition, major life changes or traumas can bring on depression.

Forms of depression differ slightly, or they may develop under unique circumstances, such as:

• Persistent depressive disorder
• Perinatal (before or after birth) or postpartum depression
• Psychotic depression 
• Seasonal affective disorder
• Bipolar depression

A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years or more.

People with perinatal or postpartum depression experience full-blown major depression during pregnancy or after delivery. This is different from the "baby blues," which are mild symptoms of depression that clear up in about two weeks.  The feelings of sadness, anxiety or exhaustion that accompany perinatal and postpartum depression may make it difficult for mothers to complete daily care activities for themselves or for their loved ones.

The postpartum period also requires many adjustments for fathers that can increase the risk for depression. Male postpartum depression or "sad dad syndrome" is also a crippling depression. It's estimated to occur in up to 25% of men in the first two months after their children are born.

When a person is severely depressed with psychotic depression, they lose touch with reality. This is exhibited by psychotic episodes, which involve having false beliefs or delusions, or hearing or seeing things that aren't there.

Seasonal affective disorder, or SAD, is the onset of depression during the winter months or where there is less natural sunlight. This form of depression, typically accompanied by social withdrawal, fatigue and weight gain, predictably returns every year.

Bipolar disorder, once known as manic depression, is different from depression. Someone with bipolar disorder symptoms can experience instances of extremely low moods that meet the criteria for major depression or bipolar depression. Unlike other types of depression, a person with bipolar disorder also experiences extreme euphoric moods, also called highs, hypomania or mania.

Depression does not have a clear pattern of running in families. However, people with a closely linked biological relative (like a parent, sister or brother) with depression appear to have a two to three times greater risk of developing the condition than the general public. However, having a family member with depression is not a predictor of depression. Many people who develop depression do not have a family history of depression, and many people with a relative with depression never develop the disorder themselves.

Children are not immune to depression. Like adults, if children are sad, irritable or no longer enjoy things over weeks or months, these may be signs that they are suffering from depression. Oftentimes, people overlook depression in children. Multiple studies in the U.S. indicate that roughly 40% of children and adolescents with depressive disorders are not treated.

Although common symptoms of depression in children and adolescents mimic those of adults, children may also have more physical complaints, such as frequent headaches or stomachaches. Depressed children and adolescents may use alcohol or drugs as a way to medicate themselves and feel better. There has been some speculation of a link between attention deficit hyperactivity disorder (ADHD) and depression. It's true that children with ADHD are at risk for depression, but treatment of ADHD might lessen the risk for depression; therefore, the conditions do not necessarily go hand in hand.

If you think a child or teenager might be depressed, it is important to seek help through a healthcare provider, school counselor or other qualified professional. They can help find the right professional to assess, diagnose and treat the child.

Depression and anxiety disorders are different. Anxiety is characterized by lengthy preparation for a real or perceived threat, and it can happen with or without depression. However, people with an anxiety disorder often experience symptoms similar to those of depression, such as nervousness, irritability and problems sleeping and concentrating. There is no evidence one disorder causes the other, but there is clear evidence that many people suffer from both anxiety and depression.

Overcoming depression depends on the type of depression and its severity. For most people, anti-depression therapies such as psychotherapy and medications yield better results together than either alone.  Brain stimulation therapies and complementary and alternative medicine may also be helpful in some cases when combined with other treatments.

Psychotherapy

Examples of evidence-based types of psychotherapy include:

• Cognitive behavioral therapy, which involves changing negative thinking patterns associated with depression and learning positive coping mechanisms. 
• Interpersonal therapy, which focuses on improving problems in personal relationships and other life changes that may be contributing to depressive disorder.
• Psychodynamic therapy helps to recognize and understand behavior and feelings that are rooted in experiences and unconscious processes, which can then be addressed.

Medications

For some people, antidepressants will reduce or control symptoms. However, these medications may take up to four weeks to begin having an effect and up to 12 weeks to reach full effect. Also, it's common to have to try various medications or doses of medications to find out what works for each individual. 

Medications used to treat depression include:

• Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and sertraline among others, which increase levels of serotonin, a brain chemical that affects emotions and mood.
• Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, which increase levels of the brain chemicals serotonin and norepinephrine, which play a role in happiness and satisfaction.
• Norepinephrine-dopamine reuptake inhibitors (NDRIs), such as bupropion and mirtazapine, which increase the concentration of dopamine and norepinephrine in the brain.
• Second-generation antipsychotics or atypical antipsychotics, like aripiprazole and quetiapine, which are used for treatment-resistant depression to augment the action of antidepressants.
• Tricyclic antidepressants are older medications that are used when other antidepressants have not worked. They carry a risk of severe side effects and have a low threshold for overdose. Examples include amitriptyline and doxepin.
• Monoamine oxidase inhibitors (MAOIs), like phenelzine and tranylcypromine are older medications that can be effective when other antidepressants haven't worked. These medications require dietary restrictions and there are some safety concerns.

Brain stimulation therapies  

For some people with depression, brain stimulation therapies may be effective. These therapies interact with the intra and inter networks of the brain, alleviating depression symptoms. They are not typically used unless other treatments haven't worked. In some cases, these therapies or their use for depression is still experiment.

• Electroconvulsive therapy (ECT) involves transmitting short electrical impulses into the brain.
• Repetitive transcranial magnetic stimulation (rTMS) stimulates the brain using a magnet instead of an electrical current.
• Magnetic seizure therapy (MST) borrows certain aspects from both ECT and rTMS. It uses magnetic pulses instead of electricity to stimulate a precise target in the brain.
• Vagus nerve stimulation (VNS), originally used to treat epilepsy, involves implanting a device under the skin that sends electrical pulses through a prominent nerve in the body.
• Deep brain stimulation (DBS) uses a pair of electrodes implanted in the brain and controlled by a generator implanted in the chest to provide continuous stimulation at a level and frequency customized to the individual.

Complementary and alternative medicine (CAM) natural depression remedies

Relying solely on CAM methods is not enough to treat depression. But some CAM treatments may be useful when combined with psychotherapy and medication:

• Exercise, which increases endorphins and stimulates norepinephrine, can improve a person’s mood.
• Folate can help antidepressants work better in some people.
• St. John's wort has similar chemical properties to some SSRIs. However, there are substantial risks to combining the two medications. St. John's wort should never be taken with a prescription antidepressant. 

Depression is a very real disease, and it’s best treated through a combination of therapy and medications. The key to successful treatment is finding the right mental health provider and knowing that there is not a one-size-fits-all solution to this illness. It might take a while to find the right therapy, but once it is found, the person will feel better.

**If you or a loved one is struggling with suicidal thoughts, free and confidential help is available 24/7 by calling 988 to speak with a trained counselor from the Suicide Prevention Lifeline, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). They have options for Spanish speakers and Deaf and Hard of Hearing as well.

Clinically reviewed and updated January 2022.