Major depression

Causes

The exact cause of depression is not known. Many researchers believe it is caused by chemical changes in the brain. This may be due to a problem with your genes, or triggered by certain stressful events. More likely, it's a combination of both.

Some types of depression run in families. But depression can also occur if you have no family history of the illness. Anyone can develop depression, even kids.

The following may play a role in depression:

• Alcohol or drug abuse
• Certain medical conditions, including underactive thyroid, cancer, or long-term pain
• Certain medications such as steroids
• Sleeping problems
• Stressful life events, such as:
  • Breaking up with a boyfriend or girlfriend
  • Failing a class
  • Death or illness of someone close to you
  • Divorce
  • Childhood abuse or neglect
  • Job loss
  • Social isolation (common in the elderly)

See also: Adolescent depression

Symptoms

Depression can change or distort the way you see yourself, your life, and those around you.

People who have depression usually see everything with a more negative attitude. They cannot imagine that any problem or situation can be solved in a positive way.

Symptoms of depression can include:

• Agitation, restlessness, and irritability
• Becoming withdrawn or isolated
• Difficulty concentrating
• Dramatic change in appetite, often with weight gain or loss
• Fatigue and lack of energy
• Feelings of hopelessness and helplessness
• Feelings of worthlessness, self-hate, and guilt
• Loss of interest or pleasure in activities that were once enjoyed
• Thoughts of death or suicide
• Trouble sleeping or too much sleeping

Depression can appear as anger and discouragement, rather than feelings of sadness.

If depression is very severe, there may also be psychotic symptoms, such as hallucinations and delusions.

Exams and Tests

Your health care provider will ask questions about your medical history and symptoms. Your answers and certain questionnaires can help your doctor diagnose depression and determine how severe it may be.

Blood and urine tests may be done to rule out other medical conditions with symptoms similar to depression.

Treatment

In general, treatments for depression include:

• Medications called antidepressants
• Talk therapy, called psychotherapy

If you have mild depression, you may only need one of these treatments. People with more severe depression usually need a combination of both treatments. It takes time to feel better, but there are usually day-to-day improvements.

If you are suicidal or extremely depressed and cannot function you may need to be treated in a psychiatric hospital.

MEDICATIONS FOR DEPRESSION

Drugs used to treat depression are called antidepressants. Common types of antidepressants include:

• Selective serotonin re-uptake inhibitors (SSRIs), including fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
• Serotonin norepinephrine reuptake inhibitors (SNRIs), including desvenlafaxine (Pristiq), venlafaxine (Effexor), and duloxetine (Cymbalta).

Other medicines used to treat depression include:

• Tricyclic antidepressants
• Bupropion (Wellbutrin)
• Monoamine oxidase inhibitors

If you have delusions or hallucinations, your doctor may prescribe additional medications.

WARNING: Children, adolescents, and young adults should be watched more closely for suicidal behavior, especially during the first few months after starting medications.

If you do not feel better with antidepressants and talk therapy, you may have treatment-resistant depression. Your doctor will often prescribe higher (but still safe) doses of an antidepressant, or a combination of medications. Lithium (or other mood stabilizers) and thyroid hormone supplements also may be added to help the antidepressants work better.

St. John's wort is an herb sold without a prescription. It may help some people with mild depression. However, it can change the way other medicines work in your body, including antidepressants and birth control pills. Talk to your doctor before trying this herb.

CHANGES IN MEDICATIONS

Sometimes, medications that you take for another health problem can cause or worsen depression. Talk to your doctor about all the medicines you take. Your doctor may recommend changing your dose or switching to another drug. Never stop taking your medications without first talking to your doctor.

Women being treated for depression who are pregnant or thinking about becoming pregnant should not stop taking antidepressants without first talking to their doctor.

TALK THERAPY

Talk therapy is counseling to talk about your feelings and thoughts, and help you learn how to deal with them.

Types of talk therapy include:

• Cognitive behavioral therapy teaches you how to fight off negative thoughts. You will learn how to become more aware of your symptoms and how to spot things that make your depression worse. You'll also be taught problem-solving skills.
• Psychotherapy can help you understand the issues that may be behind your thoughts and feelings.
• Joining a support group of people who are sharing problems like yours can also help. Ask your therapist or doctor for a recommendation.

OTHER TREATMENTS FOR DEPRESSION

• Electroconvulsive therapy (ECT) is the single most effective treatment for severe depression and it is generally safe. ECT may improve mood in people with severe depression or suicidal thoughts who don't get better with other treatments. It may also help treat depression in those who have psychotic symptoms.
• Transcranial magnetic stimulation (TMS) uses pulses of energy to stimulate nerve cells in the brain that are believe to affect mood. There is some research to suggest that it can help relieve depression.
• Light therapy may relieve depression symptoms in the winter time. However, it is usually not considered a first-line treatment.

Support Groups

You can often ease the stress of illness by joining a support group whose members share common experiences and problems.

See: Depression support group

Outlook (Prognosis)

Some people with major depression may feel better after taking antidepressants for a few weeks. However, many people need to take the medicine for 4 - 9 months to fully feel better and prevent the depression from returning.

People who have repeated episodes of depression may need quick and ongoing treatment to prevent more severe, long-term depression. Sometimes people will need to stay on medications for long periods of time.

Possible Complications

People who are depressed are more likely to use alcohol or illegal substances.

Complications of depression also include:

• Increased risk of health problems
• Suicide

When to Contact a Medical Professional

If you have thoughts of suicide or harming yourself or others, immediately call your local emergency number (such as 911) or go to the hospital emergency room.

You may also call a suicide hotline from anywhere in the United States, 24 hours a day, 7 days a week: 1-800-SUICIDE or 1-800-999-9999.

Call your doctor right away if:

• You hear voices that are not there.
• You have frequent crying spells with little or no reason.
• Your depression is disrupting work, school, or family life.
• You think that your current medications are not working or are causing side effects. Never change or stop any medications without first talking to your doctor.

Prevention

Do not drink alcohol or use illegal drugs. These substances can make depression worse and might lead to thoughts of suicide.

Take your medication exactly as your doctor instructed. Ask your doctor about the possible side effects and what you should do if you have any. Learn to recognize the early signs that your depression is getting worse.

The following tips might help you feel better:

• Get more exercise
• Maintain good sleep habits
• Seek out activities that bring you pleasure
• Volunteer or get involved in group activities
• Talk to someone you trust about how you are feeling
• Try to be around people who are caring and positive

Alternative Names

Depression - major; Unipolar depression; Major depressive disorder

References

Fava M, Cassano P. Mood disorders: Major depressive disorder and dysthymic disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 29.

American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed January 22, 2010.

Little A. Treatment-resistant depression. Am Fam Physician. 2009;80:167-172.

Update Date: 3/7/2012

Updated by: Fred K. Berger, MD, Addiction and Forensic Psychiatrist, Scripps Memorial Hospital, La Jolla, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.