Chapter One: Understanding Depression
Depression is a natural, human response to events that occur within our environment. We have all felt sad, blue, low, or ‘depressed’ from time-to-time. This mood can be triggered for a variety of reasons, usually short-lived. For most individuals, depression does not interfere with one’s daily life.
However, for many individuals, depression is a serious debilitating health concern that affects both the mind and body.
The World Health Organisation ( W.H.O. )
- Depression is a common brain function disorder. Globally, more than 350 million people of all ages suffer from depression.
- Depression is the leading cause of disability worldwide and is a major contributor to the global burden of disease.
- One in five people will suffer depression during their lifetime.
- Although there are known, effective treatments for depression, fewer than half of those affected in the world ( in some countries, fewer than 10% ) receive such treatments.
- Barriers to effective care include a lack of resources, lack of trained health care providers, lack of understanding and support from one’s community, friends and family members, and social stigma associated with mental disorders.
- Another barrier to effective care is an inaccurate assessment. Even in some high-income countries, people who are depressed are not always correctly diagnosed, and others who do not have the disorder are occasionally misdiagnosed and prescribed antidepressants.
- More women are affected by depression than men.
- At its worst, depression can lead to suicide.
- There are effective treatments for depression.
The burden of depression and other mental health conditions is on the rise globally. A World Health Assembly resolution in May 2012 called for a comprehensive, coordinated response to mental disorders at a country level.
If you, or someone you know, has a severe depressive mood state that lasts for 2-weeks or more, and this state interferes with one’s ability to function, then this may indicate that a major depressive disorder is present. Do not take any risk. Seek professional help by talking to a doctor. If the symptoms are extreme, go to a hospital or medical clinic’s emergency room.
Types of Depression / Symptoms
- Major Depression ( Also known as Major Depressive Disorder, Chronic Major Depression or Unipolar Depression )
- Bipolar I Disorder
- Persistent Depressive Disorder
- Seasonal Affective Disorder ( SAD )
- Psychotic Depression
- Postpartum Depression
- Substance-Induced Mood Disorder ( abuse or dependence )
Major Depression is manifested by a combination of symptoms that interferes with the ability to work, study, sleep, eat and enjoy once-pleasurable activities. A Major Depressive episode may occur only once; but more commonly, several episodes may occur in a lifetime. Chronic Major Depression may require a person to continue treatment and monitor lifestyle habits on an ongoing basis. This disorder is characterized by the presence of the majority of these symptoms:
Symptoms of Major Depression include:
- Persistent sad mood
- Varying emotions throughout the day, for example, feeling worse in the morning and better as the day progresses
- Less ability to control emotions such as pessimism, helplessness, anger, guilt, ( In children and adolescents, this may be characterized as an irritable mood )
- Restlessness Irritability, anxiety, and/or angry outbursts
- Feelings of hopelessness, pessimism
- Lowered self-esteem ( or self-worth )
- Reduced capacity to experience pleasure: you can’t enjoy what’s happening now, nor look forward to anything with pleasure. Hobbies and interests once enjoyed drop off
- Changed sex drive: absent or reduced
- Reduced motivation or energy levels, fatigue, being “slowed down”: it doesn’t seem worth the effort to do anything, things seem meaningless
- Poor concentration challenged memory or have increased difficulty in making decisions: some people are so impaired that they think that they are becoming demented
- Change in sleep patterns, that is, insomnia or broken sleep ( Trouble sleeping, early-morning awakening, or oversleeping )
- Changes in appetite or weight
- Persistent physical symptoms, such as headaches, digestive disorders, and chronic pain, which do not respond to routine
- Reduced pain tolerance: you are less able to tolerate aches and pains and may have a host of new ailments
- Thoughts of death or suicide, or suicide attempts
Having one of these above features, by themselves, is unlikely to indicate depression; however, there could be other causes which may warrant medical assessment.
Dysthymia is characterized by an overwhelming yet chronic state of depression, exhibited by a depressed mood for most of the days, for more days than not, for at least 2-years. (In children and adolescents mood can be irritable and duration must be at least 1-year.) The person who suffers from this disorder must not have gone for more than 2-months without experiencing two or more of the following symptoms:
Symptoms of Dysthymia
- Appetite and/or weight changes
- Trouble sleeping, early-morning awakening, or oversleeping
- Decreased energy, fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
In addition, no Major Depressive Episode has been present during the first two years ( or one year in children and adolescents ) and there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder. Further, the symptoms cannot be due to the direct physiological effects of use or abuse of a substance such as alcohol, drugs or medication or general medical condition. The symptoms must also cause significant distress or impairment in social, occupational, educational, or other important areas of functioning.
Another type of depressive illness is ‘bipolar disorder’ ( in the past described as manic-depressive illness ). Bipolar disorder is characterized by cycling mood changes: severe highs ( mania ) and lows (depression), often with periods of normal mood in between. Sometimes the mood switches are dramatic and rapid, but usually, they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of depression. When in the manic cycle, the individual may be overactive, overtalkative, and have a great deal of energy.
Bipolar disorder is characterized by more than one bipolar episode. There are four basic types of bipolar disorder.
1. Bipolar I Disorder
The primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression that last at least seven days. Manic episodes may be so severe that the individual may require hospitalization. Depressive episodes typically last at least two weeks.
2. Bipolar II Disorder
The primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization but are sufficient to be observable by others).
3. Bipolar Disorder Not Otherwise Specified
Symptoms of the disorder exist, but do not meet diagnostic criteria for either Bipolar I or II. However, symptoms are well out of normal range for the individual.
4. Cyclothymic Disorder
A chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder but have been present for at least two years.
Mania often affects thinking, judgment, and social behavior in ways that cause serious problems. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees and unsafe sex. Mania left untreated may worsen to a psychotic state. Manic episodes are characterized by:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary)).
B. During the period of mood disturbance, three or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
Symptoms of Mania
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- Grandiose notions or increased self-esteem
- Increased talking or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained purchasing sprees, sexual indiscretions, or foolish business investments).
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
- Distractibility (i.e., attention is easily drawn toward unimportant or irrelevant external stimuli)
Depressive episodes are characterized by symptoms described above for Major Depressive Episode.
Persistent Depressive Disorder
A depression that lasts over 2 years, involving symptoms that come and go in severity. The key is that the symptoms must be present at least two years
Seasonal Affective Disorder ( SAD )
A depression starting in the winter months, usually stemming from low natural sunlight and often lifting in the summer months. Sad may be effectively treated with light therapy (Full Spectrum Lighting), but about half do not respond to treatment and benefit from a combination of therapy and medication.
A severe depression where the person has some form of psychosis along with other symptoms. This psychosis can include having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others cannot hear or see (hallucinations).
This depression occurs right after giving birth. It is much more than the “baby blues” that many women experience after giving birth when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It seriously interferes with the woman’s daily activities. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.
Substance-Induced Mood Disorder ( Abuse or Dependence )
Substance-Induced Mood Disorder is a common depressive illness of clients in substance abuse treatment. It is defined in DSM-V-TR as “a prominent and persistent disturbance of mood…that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or somatic treatment for depression, or toxin exposure). The mood can manifest as manic (expansive, grandiose, irritable), depressed, or a mixture of mania and depression.
Generally, substance-induced mood disorders will only present either during intoxication from the substance or on withdrawal from the substance and therefore do not have as lengthy a course as other depressive illnesses. However, substance use disorders also frequently co-occur with other depressive disorders. Research has revealed that people with alcoholism are almost twice as likely as those without alcoholism to also suffer from major depression. In addition, more than half of people with bipolar disorder type I (with severe mania) have a co-occurring substance use disorder.
Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime; however, there is debate among researchers as to whether substance use is a “symptom” of underlying depression or a co-occurring condition that more commonly develops in men. Nevertheless, a substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.
When a disease or disorder occurs at the same time as another but is unrelated to it, it is considered to be comorbid. Among those suffering depression, 92% also reported meeting the criteria for at least one additional mental illness. The most common mental illnesses are:
- Behavioral disorders ( ADD/ADHD, Conduct Disorder )
- Substance abuse disorders
If you or someone you know is suffering from any of these symptoms, and they persist for most of the day for more days than not over a two-week period of time, and they interfere with your ability to manage at home and at work, then you might benefit from getting an assessment by a skilled professional.
- National Institute of Mental Health
- World Health Organization
- American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association.
- Depression and Suicide in Children and Adolescents. Surgeon General’s Health Report.
If you are feeling suicidal, it is very important to seek immediate help, preferably by a mental health practitioner. Click Get Help for further helpful information.
Chapter Two: Causes of Depression
While researchers often talk about ‘finding the cause’ of some disease or disorder, this often obscures the fact that only part of the story is known about the causes of depression. Some causes are pretty straightforward. We know that a broken leg is usually the result of some kind of pressure or strain being applied. Moreover, if you have a broken leg you typically know when it happened ( leg was fine yesterday, today it is broken ) and how it happened ( this morning you went skiing ).
Things are not so simple with depression. We have good ideas about what some of the ‘pressures or strains’ that result in depression are – but they are not all agreed upon and there might be others.
For any one person, there could be many ‘pressures’ in their life. It’s often unclear when the depression started, much of the time its effect is gradual.
We can see another complication by going back to the broken leg example. Some people suffer from osteoporosis, which makes their bones more fragile ( more vulnerable ). If you only had a minor accident when you went skiing, your osteoporosis was probably as much the cause of your broken leg, since it made your leg more vulnerable to the effects of pressure. If you have a major accident, however, the leg will probably break, osteoporosis or not.
In other words, the causes of depression are some mixture of ‘pressure’ ( mild to severe ) combined with a vulnerability to depression ( as a sort of ‘psychological osteoporosis’ ) which too can range from mild to severe.
Also, for each ‘sub-type’ of depression, differing ‘mixtures of causes’ have differential relevance. So, for psychotic or melancholic depression physical and biological factors are generally more relevant. By contrast, for non-melancholic depression, the role of personality ( the presence of osteoporosis ) and life event stressors ( having an accident ) are generally far more relevant.
Chapter Three: Treatments for Depression
There are a variety of treatments for depression available. New treatments ( medications and alternative therapies, such as dietary supplements ) do appear regularly. Ongoing research provides evidence of how well a treatment works.
We have chosen to give only a brief summary of treatments and instead direct you to research other sites which provide more comprehensive details.
As early as the 1960’s, Dr. Linus Pauling, winner of two Nobel Prizes, speculated that some people have a genetically-based need for more vitamins and minerals than others. He thought about the possibilities that mental illness could be the result of failing to meet these additional requirements.
Research is in its infancy on the subject of treatments for mental illnesses such as depression, bipolar disorder, and anxiety disorder; however, it is now starting to show that this hypothesis may be correct. Dr. Bruce Ames, at the University of Berkeley, has shown that genetic mutations often result in an increased need for nutrients. He also has found that taking additional specific nutrients could correct the deficiencies.
Key Points About Treatments for Depression
- We believe that different types of depression respond best to different sorts of treatments. There is no one particular magic treatment that fits everyone.
- It is important that a thorough and thoughtful assessment be carried out before any treatment is prescribed. Do your homework and become well informed. Get a second and third opinion until you find the healthcare professional you can trust.
- Treatments for depression include both psychological and physical interventions.
- Depression can sometimes go away of its own accord but, left untreated, it may last for many months.
- Depending on the nature of your depression, self-help and alternative therapies can also be helpful, either alone or in conjunction with physical and psychological treatments.
Chapter Four: Teens, Young Adults, and Depression
Teens, young adults and depression are a major concern. One in five children and adolescents is affected by mental health problems and disorders. Those aged 18-24 have the highest prevalence of mental disorders of any age group.
Key Points About Teens, Young Adults, and Depression
- Depression in this age group should be taken seriously. Youth suicide is the most common cause of death in this age group.
- It can be hard to distinguish adolescent turmoil from depressive illness, especially as the young person is also forging new roles within the family and struggling with independence, and academic and career decisions.
- Both biological and developmental factors contribute to depression in adolescence. If bipolar disorder or psychosis is suspected biological causes would need to be examined.
- In tracking down difficulties, it can help to consider some of the areas that the adolescent is dealing with: school, family, peer group and intimate and/or sexual relationships.
Signs of Depression in an Adolescent
An adolescent who is depressed may not show obvious signs of depression. Instead, he or she may start to behave uncharacteristically, by, for example:
- Becoming socially withdrawn
- Falling in their performance at school
- Engaging in risk-taking behavior ( e.g. reckless driving, inappropriate sexual involvements )
- Engaging in drug and alcohol abuse.
Sometimes a minor physical problem is used as a disguised appeal for help.
Where to Get Help for an Adolescent
If you think your son or daughter, or someone you are close to, might be depressed, the first step is to either take them to a GP or to the local medical center. The GP will either conduct an assessment or refer the adolescent to a child and adolescent psychiatrist or mental health worker.
You could also speak to the Guidance Officer or Counsellor at your child’s school.
Sometimes the adolescent may not want to seek help. In this case, it’s best to explain that you are concerned and perhaps also provide them with some information to read about depression. There are also some excellent websites designed for young people, as well as online and telephone counseling services. It’s important for them to know that depression is a common problem and that there are people who can help.
Chapter Five: Veterans and Depression
Our cherished Veterans and depression is a concern. The ones that love you the most are the ones that are willing to fight and die for you.
- There are hundreds of thousands of homeless Veterans sleeping on the streets and this number is steadily rising.
- Over 1.4 Million ( 1,400,000 ) Veterans are at risk of becoming homeless.
- More than 67% of homeless Veterans served our country for the past 3-years.
- Veterans gave you everything, yet we all fail them.
- Divorce rates among military couples have increased 42%.
- While you are reading this, a veteran is losing his family.
- An estimated 460,000 Veterans suffer from Post-Traumatic-Stress-Disorder ( PTSD ).
- While you are reading this, a Veteran is roaming a street near you, hopeless.
- Homeless Veterans spend an average of 6-years on the streets.
- While you are reading this, a Veteran doesn’t understand, why his sacrifice goes unappreciated.
- While you are reading this, a Veteran somewhere near you is not getting any help.
- The Veterans Administration has resources to serve only a fraction or our Veterans.
- In the time that you take to watch the video below, a veteran somewhere close to you has taken his own life.
- More than 14 Veterans a day took their own life and it will happen again tomorrow. That’s one Veteran every two hours ( that’s 5000 heroes gone each year).
“The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive the Veterans of earlier wars were treated and appreciated by their nation.” — President George Washington
“My heroes are those who risk their lives every day to protect our world and make it a better place–police, firefighters, and members of our armed forces.” — Sidney Sheldon
“War may sometimes be a necessary evil. But no matter how necessary, it is always an evil, never a good. We will not learn how to live together in peace by killing each other’s children.” — Jimmy Carter
Chapter Six: Seniors and Depression
Seniors and depression are people less likely than other age groups to report depression and may not acknowledge being sad, down or depressed.
- Depression in old age often goes undetected and may be wrongly attributed to age, dementia or poor health.
- Signs of depression in adults over 65 can include unexplained physical symptoms, memory loss, and various behavioral changes.
- Causes of depression in old age will vary according to when the depression was first experienced. If depression was first experienced earlier in life, genetic, personality and life experiences will be likely causes whereas if the depression is first developed later in life, physical health problems may be the cause.
- Social isolation and loneliness commonly accompany depression in adults over 65.
- Untreated depression in old age has many adverse effects.
- Treatments for depression in old age are similar to those for other age groups but can be different in the way they’re applied.
- Age does not reduce the effectiveness of treatments for depression.
- Lifestyle changes in mid-life may be the key to preventing depression in old age.
- Your doctor is the best first port of call if you’re over 65 and experiencing depression.
“The so-called ‘psychotically depressed’ person who tries to kill him or herself doesn’t do so out of, quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing.
The person in whom Its invisible agony reaches a certain unendurable level will kill him or herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. His or her terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.” – David Foster Wallace
Chapter Seven: Medically Ill and Depression
Medically ill and Depression someone should always be assessed as soon as possible because of the links between depression and other medical causes. See your General Practitioner first. Here are some simple facts:
- It can be hard to properly diagnose depression in someone who is medically ill.
- Medical illness can trigger depression, either psychologically or physically.
- Some medical illnesses greatly increase the chance of developing depression.
- Some medications can induce depression.
- Depression may itself increase the risk of developing certain medical conditions, such as heart attack.
- Depression can prolong the recovery from certain medical illness.
Diagnosing Depression in Someone Medically Ill
Diagnosing depression in people who are medically ill can be quite complicated. This is because the standard ways of assessing depression frequently assess things such as fatigue, loss of interest and lack of energy, and, as having a medical illness is often associated with feeling this way, there is the obvious risk of non-depressed people being falsely diagnosed as having ‘depression’.
Research is being conducted in re-examining the link between depression and cardiac disease, seeking to better understand the links between the two illnesses.
If you think you or a family member who is medically ill may have depression it is best to seek professional help. Not only can depression prolong the recovery of the medical illness but the depression could be an indicator of other medical issues that may warrant proper assessment and treatment.
Medical Illness can Trigger Depression
A significant percentage of people experiencing physical illness are likely to experience a range of stress and distress symptoms, including anxiety and depression, reflecting the ‘impact’ of the physical illness.
In the initial phase of a physical illness, depression is far less common than symptoms such as anxiety and stress (e.g. what is going on, is it dangerous, is it temporary or likely to persist, does it threaten my life or not?). Depression is more likely to occur at a later stage of the illness process, particularly when some ‘loss’ is experienced. The ‘loss’ could be a loss of functioning, of ongoing good health and even the threat to life.
Medical illness can itself bring on depression or cause it to appear in the form of new physical symptoms or sensations. Put simply, it is thought that stress and depression might lower a person’s tolerance threshold so that they begin to observe physical sensations and feelings they didn’t notice before.
The other explanation is that certain illnesses ( e.g. Parkinson’s Disease, stroke, cancers of the pancreas and the lung, disordered thyroid function ) strikingly increase the chance of developing a depression. There are various physiological mechanisms at play here.
Depression Increases the Risk to Some Medical Illnesses
In recent years, we have become aware that depression may significantly increase the chance of certain medical conditions developing, and also influence their outcome. Probably the best example involves a link with heart attacks. A number of longitudinal studies have followed adults over decades and established that those who had experienced a depressive episode are at higher risk of heart attack (and with a worse outcome) than those not having had a clinical depressive episode.
The Impact of Medications
Many medications used to treat physical conditions may induce depression. Examples are some blood pressure tablets and hormone replacement therapy medications.
A further link between medical illness and depression is currently attracting increasing research interest and clinical attention. This involves the capacity of various antidepressant drugs to influence the disease process. For example, a number of studies have shown that, for those who have diabetes mellitus, some antidepressant drug classes may influence plasma insulin and glucose levels.
Further, increasing attention is being given to defining the potential for worrying drug-drug interactions, as these may have a large number of major consequences, including inducing depression.
If you are taking medications and think you may be depressed, it would be wise to see your doctor. Let him or her know what medications you are taking so he or she can assess whether any of those medications may be inducing depression.
Depression Can Hamper Recovery
With certain medical conditions, such as heart attack, being depressed around that time means that recovery can be hampered. While best established for cardiovascular disease and stroke, having a depressive disorder at the same time as having a medical illness can mean that it is more difficult to recover properly and that the risk may persist for more than two years after the illness episode.
Chapter Eight: Pregnancy and Postnatal Depression
Pregnancy and postnatal depression are a serious concern. Many women experience a brief episode of mood swings, tearfulness, anxiety, and difficulty in sleeping in the first week after the birth of a baby. Some 50-80% of women have such an experience. This episode, known as the baby blues, is thought to be linked with the stresses associated with late pregnancy, labor, and delivery, along with the rapid hormonal changes that accompany the birth.
Symptoms generally settle during the first week after birth and require no special treatment other than adequate rest and support. Only when symptoms are severe or do not clear spontaneously within the first two weeks it is important to seek medical assessment to find out if another condition is present.
These celebrity moms shared their postpartum depression publically, despite a cultural stigma against discussing motherhood in less-than-glowing terms:
In her 2001 memoir Behind the Smile: My Journey Out of Postpartum Depression, Osmond detailed her battle with depression following the birth of her son Matthew, the youngest of her eight children.
After Paltrow gave birth to son Moses in 2006, she told Vogue U.K.: “At my lowest, I was a robot. I just didn’t feel anything. I had no maternal instincts for him—it was awful. I couldn’t connect, and still, when I look at pictures of him at three months old, I don’t remember that time.”
A singer in the pop music group Wilson Phillips, Carnie Wilson suffered from postpartum depression following the birth of daughter Lola Sofia.
Wilson told People Magazine, “I cried all day over everything.”
“It’s a physical feeling. I don’t know how to describe it. You’re overwhelmed with love and joy, then sadness and fear. You’re so afraid you’re going to fail this baby,” she said. “What if you drop her or hurt her? She’s totally dependent on you and it’s scary.”
In September 2015, Nashville star revealed on Live! With Kelly and Michael that she’d suffered from postpartum depression following the birth of her daughter Kaya Evdokia in December 2014. “It’s something that I can very much relate to, and it’s something that I know a lot of women experience,” she told the hosts. “When they tell you about postpartum depression, you think about, ‘Okay, I feel negative feelings towards my child, I want to injure my child, I want to hurt my child’—I’ve never ever had those feelings, and some women do.” Two weeks after her interview, the 26-year-old’s rep confirmed in a statement that she was “voluntarily seeking professional help at a treatment center as she is currently battling postpartum depression.”