"Teachers: Nikki neuron reminds you to check the standards tables in the front of the toolkit to see which ones apply for this lesson and your subject area."
What is Depression?
We all have periods of feeling sad, down, or blue, and that is normal, but the clinical condition known as depression is more than a passing mood. Depression is characterized by pronounced, pervasive feelings of sadness and/or emptiness and significant problems in coping. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things.
Depression is not the result of a character flaw or personal weakness, nor is it a condition that can be willed or wished away. People who are depressed can not merely “pull themselves together” and get better.1,2
If you are depressed, you can not simply make yourself well by trying to “snap out of it.” The good news, however, is that depression is a very treatable medical illness. Appropriate treatment can help most people, although without treatment, symptoms can last for weeks, months, or years, sometimes returning with worsening severity. 3,4, 5
The direct causes of depression are unclear. However abnormal function of certain brain chemicals called neurotransmitters is associated with depression, with onset often following a traumatic event, hormonal changes, altered health habits, the presence of another illness, or substance abuse.6 Although depression can run in families, it is not contagious. As with other illnesses such as heart disease, depression can come in different forms. Mental health professionals have identified several types of mood disorders that have depression as a component. The main classes of mood disorders are
- Depressive disorders
- Bipolar disorders
- Substance-induced mood disorders
- Mood disorders due to a general medical condition
Within each class are subtypes, most of which will not be discussed here.
Two of the most common depressive disorders are major depressive disorder and dysthymia.
Major Depressive Disorder. To be diagnosed as having major depressive disorder, a person must experience for at least two weeks either
- A depressed mood: pervasive feelings of sadness and/or emptiness (in children and adolescents, can be irritability or frustration) or
- Loss of interest or pleasure in activities and at least four additional symptoms of the following:
- Significant changes in appetite; weight gain or loss
- Insomnia or excessive sleeping
- Chronic and high levels of irritability or agitation or
- The opposite: persistently slow moving or sluggish
- Loss of energy, persistent lethargy or fatigue
- Excessive or inappropriate feelings of guilt or worthlessness
- Inability to concentrate or indecisiveness
- Recurring thoughts of death or suicide
An evaluation by a trained mental health professional is essential for proper diagnosis. Anyone experiencing symptoms of depression for more than two weeks should get a thorough evaluation by a physician to be sure a medical condition is not causing the symptoms.8
Other health care providers trained to diagnose and treat depression include psychologists, social workers, counselors, and psychiatric nurses. Care of the depressed patient is often a collaborative effort between one of these mental health professionals, who provide psychotherapy, and a medical doctor. However, only medical doctors have the training and license to prescribe medication, which can be effective in treatment for depression. Medical doctors qualified to prescribe medications can be of any physician specialty including, of course, psychiatry as well as family or general practice.
A disabling depressive episode may occur only once in a lifetime, but may recur – once a month, once a year, or several times over decades. In rare cases, the illness is so severe that a person becomes psychotic, or incapable of distinguishing between reality and delusion. For instance, one suffering from psychotic depression may have the false belief that he has committed mistakes that are so grave that God is punishing him and all humanity.
Dysthymia. This condition is milder than major depressive disorder, but it is chronic – at least two years for adults and one year for children and adolescents. People with dysthymia are in a sad or depressed mood most of the time, with at least two of these symptoms: poor appetite or overeating, insomnia or oversleeping, low energy or fatigue, feelings of hopelessness, poor concentration or difficulty making decisions, or low self-esteem. Dysthymia interferes with functioning and keeps people from feeling really good about themselves or living to their fullest potential. Many people with dysthymia experience a major depressive episode at some time in their lives.
Bipolar disorder is a type of serious mental illness, once called manic-depression, in which an individual alternates between periods of extreme depression and mania. Several subtypes of bipolar disorder have been identified, with varying symptoms, severity and duration. In one type, the mixed episode, the manic and depressed symptoms occur simultaneously.
According to diagnostic criteria, manic episodes last at least a week and are characterized by highly energetic, driven behavior and thinking, during which an individual may have racing thoughts, unrealistically positive or grandiose expectations, inflated views of one’s abilities, little need for sleep, a tendency to talk about a number of rapidly changing subjects, a propensity for getting heavily involved in a number of projects without finishing them, and excessive involvement in pleasurable or high-risk activities to the extent that they may risk experiencing negative consequences. At such times, self-esteem is often highly inflated beyond reasonable proportions. Mania can become severe enough that psychosis (failure to differentiate reality from unreality) develops. In most cases, the mania is followed by a “crash,” and the person becomes profoundly depressed, irritable or angry.
Some forms of bipolar disorder are less severe, but others seriously disrupt life for the person with the illness, as well as his or her family, friends and coworkers, and may require that the person be hospitalized. Someone in a manic episode is often the
last to realize or acknowledge that he or she needs help. In most cases, medication helps control these cycles of extreme highs and lows, but hospitalization is sometimes necessary. For some individuals, psychotherapy helps reduce the severity and frequency of periods of illness, although medication is still required for control of symptoms.1
Substance-Induced Mood Disorders
A person’s moods can become severely altered as the direct result of exposure to a substance, which could be an environmental toxin, medication or illicit drug. Symptoms vary with the type and intensity of the exposure and in some cases can last up to four weeks after exposure has ceased. Symptoms may include extreme depression or loss of interest in once pleasurable activities, mania, or a combination. Mood Disorder Due to a Medical Condition7 A person’s moods can be severely altered as the direct result of a physical disease. Symptoms may include extreme depression or loss of interest in once pleasurable activities, mania or a combination. This condition is more than being depressed because one is physically sick; it is brought on by a disease causing physiological changes that affects a person’s emotions and thinking patterns. A spectrum of medical problems can induce depression including degenerative neurological diseases, such as Parkinson’s disease, stroke, B-12 vitamin deficiency, endocrine dysfunction (particularly of the thyroid gland), autoimmune diseases such as lupus and AIDS, and some cancers.
Other Types of Depression
As noted earlier, depression can have various causes, biological or environmental, or an interaction of multiple factors. Described here are two types of depression that are induced by external factors interacting with a person’s physiology.
Postpartum Depression. This type of depression sometimes occurs in women following childbirth. Estimates are that 10-15% of adult mothers and more than 25% of adolescent mothers develop this disorder, which generally begins a month after childbirth and lasts at least two to three weeks. Some researchers believe that this type of depression may in part be due to hormonal changes during pregnancy and after childbirth.
Symptoms are similar to major depression and may include feelings of worthlessness or guilt especially related to failure as a mother, as well as mania, excessive anxiety about the child’s health, and fear of being alone with or harming the baby or oneself. In rare cases, symptoms include psychotic hallucinations in which the mother believes she is being “commanded” to harm or kill her baby.9 Postpartum depression is much more severe than “baby blues,” which affects up to 70% of mothers, is a passing state of mild anxiety and unhappiness and does not significantly impair one’s ability to cope. It is extremely important for a mother of a newborn to talk about any postpartum feelings of depression with her doctor.
Over time, if left untreated, serious depression can affect the mother-child relationship and in severe cases may put the infant’s or mother’s life at risk.9 Seasonal Affective Disorder (SAD). This type of depression results from reduced sunlight during the fall and winter. Younger people, women and people who live in higher latitudes, especially the extremes, are more prone to developing SAD.10 Symptoms, which include loss of energy, oversleeping, overeating, a craving for carbohydrates, and weight gain, generally disappear in the spring, although there are rare summertime recurrences. For those who suffer from SAD, increased environmental lighting of specific types may be an effective treatment.
Prevalence: Who Gets Depressed?
People of all ages, races, ethnic groups and social classes can become depressed. In any given one-year period, 9.5% of the adult U.S. population, or about 18.8 million people, suffer from a depressive illness. Age. Although depression can strike at any age, its onset is typically between the ages 24 and 44.13 Fifty percent of people with major depressive disorder experience their first episode of depression around age 40 or later, but studies show that the average age of onset for a major depressive episode may be shifting to the 30’s.
Teenagers are at greater risk for depression than ever, although part of this increase could simply reflect improved ability to recognize depression as it is manifested during adolescence.14,15 Teen suicide rates are increasing every year, due in part to increased prevalence of depression. The rise in the rate of depression among teenagers may reflect intensifying societal pressures such as expectations of peers and parents, academic or vocational demands, and negative cultural influences. Depression is even seen in younger children, although the symptoms are not always as easy to recognize at young ages.
- Depression in children. As many as one in 33 children and one in eight adolescents are depressed.14,15 If a child has five or more symptoms for at least two weeks or if symptoms interfere with his or her daily activities (e.g., going to school, playing with friends), then he/she may be clinically depressed. Other warning signs of childhood depression include irritability, physical complaints such as stomach problems or headaches, frequent absences from school, declining grades, social isolation and reckless behavior. Fortunately, treatment for childhood depression is often very effective. Research is now indicating that early diagnosis and treatment may lessen future depressive episodes.
- Depression among the elderly.12,16 Depression is not a normal part of aging. Of the more than 32 million Americans over the age of 65, nearly five million experience serious symptoms of depression, and one million suffer from a major depressive disorder. Elderly people with untreated depression are more likely to have worse outcomes from treatment of co-existing medical illnesses (e.g., hypertension, diabetes, heart disease). Untreated depression is the most common psychiatric disorder and the leading cause of suicide in the elderly.
Race and Class. Although there does not seem to be a remarkable correlation between depression and race or class, depression is diagnosed more often in Caucasian people from the middle and upper classes than in other ethnic groups. It is speculated that cultural differences between patient and therapist may account for this fact. Because most therapists are Caucasian, they may not recognize the condition among African-American, Asian, or Latino people as frequently as it occurs. Furthermore, people of lower socioeconomic class often can not afford to seek treatment and thus may have limited access to care.
Gender. Major depressive disorder can affect from 5 to 12% of men and from 10 to 25% of women at some point in their lifetime.1,7,9 The reasons for the disparity between genders is unclear. One theory is that hormonal fluctuations may put women at a higher risk for depression, but there is no solid evidence to support this theory. Some researchers believe the hormonal and life changes associated with menstruation, pregnancy, miscarriage, the postpartum period and menopause may contribute to, or trigger, depression. The disparity in rates of depression reported for men and women may also reflect behaviors based on socialization of gender roles.1 Learned helplessness coupled with socioeconomic stressors may result in more depression among women. Although men are less likely to suffer from depression than women, three to four million men in the United States are affected by the illness. Men are less likely to admit to or seek help for depression, and doctors are less likely to suspect it.2,9 The socialization of men, which demands self-sufficiency and emotional toughness, may deter them from seeking treatment. Depression in men is often masked by alcohol or drugs or by the socially acceptable habit of working excessively long hours. Depression in men often manifests as irritability, anger, and discouragement, although the more classic symptoms may also occur. Even if a man believes he may be depressed, he may be less willing than a woman to seek help. Support and encouragement from family and friends can make a difference.
Course of Depression and Outcomes
Depression may begin at any age. Symptoms usually begin gradually, often taking weeks or months for a major depressive episode to develop. Left untreated, an episode typically lasts a minimum of six months. With treatment, the length of the episode may be greatly reduced.1 Once an episode is resolved, many individuals return to full functioning, but 20% to 35% may have persistent symptoms that impair social and occupational functioning. Approximately 50% of those who have had one depressive episode will have another at some point in their lives. With each episode, the risk for more episodes increases. But again, the good news is that depression is a highly treatable illness.6 Suicide. The most devastating outcome of untreated depression is suicide. (See note in section on suicide in student handout.)
A very common symptom of depression is pessimism – the tendency to view one’s self, life, and future in unrealistically negative ways. For the person who is pessimistic and also preoccupied with death or suicide — another common symptom of depression — the likelihood of suicide increases. However, most depressed persons do not commit suicide. Those who recover from depression and gain a more realistic outlook on life look back on their past suicidal impulses and are thankful to have not acted on them.
For those 15 to 25 years old, suicide is the third leading cause of death.17 If someone seems depressed, it is important to find out if the person has suicidal ideas, plans or intent. One should not delay in giving support and arranging for treatment to lessen the chance of suicide. It may help to “contract” with the depressed person so that he will promise to not hurt himself or will call a friend or mental health professional immediately if thoughts of suicide return.
Risk Factors for Depression
Genetic research has shown that children whose parents suffer from depression are at increased risk of developing the disorder.18 Further, anyone with a history of depression is at higher risk of having subsequent episodes of depression. Women overall are at greater risk of depression than men. Depression is more common among people who have a history of trauma, sexual abuse, physical abuse, physical disability, loss of a loved one at a young age, alcoholism, or unstable family structure. In adults, the loss of a spouse, either through death or divorce, is the most common cause of a depressive episode. Women are at increased risk for depression during and within the first few months after pregnancy. Chronic depression may be more common in areas afflicted with war, natural disasters, poverty, or neglect. A number of factors are associated with increased risk for depression, including:
- Being older
- Having symptoms of anxiety
- Involvement with substance abuse
- Exposure to stressful life events such as marital conflict, early childhood physical or sexual abuse, poor relations with peers, and having a learning disability
- Major life changes, particularly the death of a spouse or loved one
- Change in health status
- Chronic pain
- Family or personal history of depression
- Social isolation
- A negative/pessimistic outlook and perception of self and others may be predisposing factors to depression.1-9
- Research has shown that several cognitive factors (which affect judgment and perception) are associated with depression.18 Major cognitive risk factors include:
- Chronic low self-esteem
- Distorted perception of others’ views
- Distorted sense of life experience
- Inability to acknowledge personal accomplishment
- Negative idea of self
- Pessimistic outlook
- Quick and exaggerated temper
Depression and Co-Morbidity
Morbidity is sickness. Co-morbidity simply means having more than one illness at the same time. Research has found that certain illnesses tend to occur together. As noted earlier, research indicates that certain medical problems, including stroke, heart attack, Parkinson’s disease, and some cancers and hormonal disorders, can cause depression.
Co-occurring depression often goes undetected. Several recent studies have found that treatment for co-occurring depression enhances quality of life, reduces the degree of pain and disability experienced by the medical patient and substantially improves the prognosis.19 Depression and medical illnesses may occur together for different reasons:
- The medical illness may contribute biologically to depression, as in the case of an under-active thyroid gland or the adrenal gland disease, Cushing’s Disease.
- People who are sick may become depressed as a psychological reaction to the prognosis, pain, or incapacity caused by the disease or its treatment, as in cancer.
- Although occurring together, depression and the medical illness may be unrelated.
Depression also often co-exists with other mental disorders. Substance abuse, anxiety disorders and eating disorders are conditions that are commonly accompanied by depression and are made worse if left untreated. When a depressed person also has a substance abuse problem, it is generally necessary to treat the substance abuse problem first before initiating treatment for the depression. Without gaining control of the substance abuse, any treatment for depression will likely be of limited effectiveness.
Depression: The Social and Economic Costs
Depression is among the most common of chronic health problems. It is associated with higher societal costs than many other chronic diseases, especially when put in terms of diminished quality of life and productivity for those who suffer from depression.
The economic costs alone are staggering. In 1990, mental disorders of all types cost the nation an estimated $148 billion. This figure includes treatment costs of $67 billion (10 percent of the total annual direct cost of health care in the United States) and $63 billion in lost productivity due to illness. More than $11 billion in other costs accrued from decreased productivity due to symptoms that sap energy, affect work habits, cause problems with concentration, memory, and decision-making, and increased demands on social services and the criminal justice system.20 No job category or professional level is immune. The estimated costs go even higher if losses associated with alcoholism or drug abuse are included. Research has attributed much of the staggering economic costs associated with depression to limited access to mental health,21 which worsens length of illness and problems of poor work performance and absenteeism.
The greatest human cost of depression is the increased risk for suicide. Although most individuals with depression will never harm themselves, many will at least think about suicide and some will act on those thoughts, which accounts in part for the increased risk of injury and death for persons with depression. In 1997, for ages 10-24, suicide was the third leading cause of death according to the National Institute of Mental Health.2 For depressed adolescents in particular, alcohol or substance abuse increases the risk of suicide.
Sometimes, a depressed person may act out a suicidal plan with no intention of succeeding, but simply in an attempt to get attention and help. Unfortunately, sometimes such an act succeeds, so any mention of suicide, even if it seems like empty words, should be taken very seriously and arrangements should be made to ensure that the troubled individual is helped by a mental health professional.17,22,23 The impact of depression extends beyond the life of the person who is depressed. This illness can devastate the person’s family and other loved ones. But much of this suffering and cost is unnecessary. The good news is that, in more than 80% of cases, treatment brings some degree of relief, enabling most people with depression to return to satisfying, productive lives.
- Mental illness – depression. National Foundation for the Depressive Disorders Web site. Available at www.depression.org. Accessed August 4, 2002.
- Depression – what you need to know. National Institute of Mental Health Web site. Available at www.nimh.nih.gov. Accessed August 4, 2002.
- Hirschfield RM, Keller MB, Panico S, et al.
- The National Depressive and Manic-Depressive Association consensus statement on the under treatment of depression. JAMA. 1997;277(4):333-340.
- Weissman MM, Wok S, Goldstein RB, et al. Depressed adolescents grow up. JAMA. 1999;281(18):1707-1713.
- Sussman LK, Robins LN, Earls F. Treatment-seeking for depression by black and white Americans. Social Science and Medicine. 1987;24:187-196.
- Mental health: a report of the surgeon general.
- Available at www.surgeongeneral.gov/library/ mentalhealth. Accessed October 12, 2002.
- Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association; 2000.
- Facts about depression: depression research at the National Institute of Mental Health. Available at www.nimh.gov. Accessed October 14, 2002
- Blehar MD, Oren DA. Gender differences in depression. Medscape Women’s Health. 1997;2-3. Revised from: Women’s increased vulnerability to mood disorders: integrating psychology and epidemiology. Depression. 1995;3:3-12.
- Seasonal Affective Disorder. National Association for the Mentally Ill Web site. Available at: www.nami.org. Accessed October 14, 2002.
- Lu FG, Lim RF, Mezzich JE. Issues in the assessment and diagnosis of culturally diverse individuals. In Oldham J, Riba M, eds. Review of Psychiatry. Vol 14. Washington, DC: American Psychiatric Press; 1995.
- Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Archives of General Psychiatry. 1994;51:8-19.
- Regier DA, Farmer ME, Rae DS, et al. One-month prevalence of mental disorders in the United States and sociodemographic characteristics:
- The Epidemiologic Catchment Area Study. Acta Psychiatrica Scandinavica. 1993;88 :35-47.
- Bushong C, Coverdale J, Battaglia J. Adolescent mental health: A review of preventive interventions. Journal of Texas Medicine. 1992;88(3):62-67.
- Blum R. Contemporary threats to adolescent health in the United States. JAMA. 1987;257(24):3390-3395.
- The 12-month prevalence and correlates of serious mental illness. In Mental Health, United States. Washington, DC: US Government Printing Office;
- 1996. Department of Health and Human Services publication (SMA) 963098:59-70
- National Strategy for Suicide Prevention. Center for Mental Health Services, Department of Health and Human Services, USA. Accessed November 3, 2003. http://www.mental health.samhsa.gov/suicideprevention/default.asp.
- Werner EE, Smith RS. Overcoming the Odds: High-Risk Children from Birth to Adulthood. New York, NY: Cornell University Press; 1992.
- Murray CJ, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk
- Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard School of Public Health; 1996.
- Sturm R, Wells KB. How can care for depression become more cost-effective? JAMA. 1995;74(1):51-58.
- Rosenheck RA, Druss B, Stolar M, et al. Effect of declining mental health service use on employees of a large corporation. Health Affairs. 1999;18:193-203.
- Wells KB, Sturm R. Care for depression in a changing environment. Health Affairs.14(3):78-89.
- APA Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. 2nd ed. Available at: www.psych.org/clinres/ Depression2e.book.cfm. Accessed October 14, 2002.
Sponsored by the UAMS College of Medicine, Department of Psychiatry’s Partners in Behavioral Health Sciences program which is made possible by support from a Science Education Partnership Award (R25 RR15976) from the National Center for Research Resources at the National Institutes of Health.University of Arkansas, Board of Trustees © 2002. All rights reserved. 1-12