Depression - More Detail

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her.

Depression is a common but serious illness, and most who experience it need treatment to get better.

Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment.

Intensive research into depression has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling condition.

What causes depression?
There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression.

The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior appear to function abnormally. In addition, important neurotransmitters (the chemicals that brain cells use to communicate) appear to be out of balance. But these images do not reveal why the depression has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well.⁹ Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.¹⁰

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

How do women experience depression?
Depression is more common among women than among men. Researchers are examining many potential causes for and contributing factors to women's increased risk for depression. It is likely that genetic, biological, chemical, hormonal, environmental, psychological, and social factors all intersect to contribute to depression.

Genetics
If a woman has a family history of depression, she may be more at risk of developing the illness. However, this is not a hard and fast rule. Depression can occur in women without family histories of depression, and women from families with a history of depression may not develop depression themselves.

Genetics research indicates that the risk for developing depression likely involves the combination of multiple genes with environmental or other factors.³

Chemicals and hormones
Brain chemistry appears to be a significant factor in depressive disorders. Modern brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people suffering from depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior don't appear to be functioning normally.

In addition, important neurotransmitters-chemicals that brain cells use to communicate-appear to be out of balance. But these images do not reveal WHY the depression has occurred.

Scientists are also studying the influence of female hormones, which change throughout life. Researchers have shown that hormones directly affect the brain chemistry that controls emotions and mood.

Specific times during a woman's life are of particular interest, including puberty; the times before menstrual periods; before, during, and just after pregnancy (postnatal); and just prior to and during menopause (perimenopause).

Premenstrual dysphoric disorder (PMDD)
Some women may be susceptible to a severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD), a condition resulting from the hormonal changes that typically occur around ovulation and before menstruation begins. Women affected by PMDD typically experience depression, anxiety, irritability and mood swings the week before menstruation, in such a way that interferes with their normal functioning.

Women with debilitating PMDD do not necessarily have unusual hormone changes, but they do have different responses to these changes.⁴ They may also have a history of other mood disorders and differences in brain chemistry that cause them to be more sensitive to menstruation-related hormone changes.

Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.^5,6,7

Postnatal Depression
Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming.

Many new mothers experience a brief episode of the "baby blues," but some will develop postnatal depression, a much more serious condition that requires active treatment and emotional support for the new mother. One study found that postnatal women are at an increased risk for several mental disorders, including depression, for several months after childbirth.⁸ Some studies suggest that women who experience postnatal depression often have had prior depressive episodes. Some experience it during their pregnancies, but it often goes undetected.

Research suggests that visits to the doctor may be good opportunities for screening for depression both during pregnancy and in the postnatal period.^9,10

Menopause
Hormonal changes increase during the transition between premenopause to menopause. While some women may transition into menopause without any problems with mood, others experience an increased risk for depression.

This seems to occur even among women without a history of depression.^11,12 However, depression becomes less common for women during the post-menopause period.¹³

Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.¹¹

Stress
Stressful life events such as trauma, loss of a loved one, a difficult relationship or any stressful situation-whether welcome or unwelcome-often occur before a depressive episode. Additional work and home responsibilities, caring for children and aging parents, abuse, and poverty also may trigger a depressive episode.

Evidence suggests that women respond differently than men to these events, making them more prone to depression. In fact, research indicates that women respond in such a way that prolongs their feelings of stress more so than men, increasing the risk for depression.¹⁴

However, it is unclear why some women faced with enormous challenges develop depression, and some with similar challenges do not.

What illnesses often coexist with depression in women?
Depression often coexists with other illnesses that may precede the depression, follow it, cause it, be a consequence of it, or a combination of these.

It is likely that the interplay between depression and other illnesses differs for every person and situation. Regardless, these other coexisting illnesses need to be diagnosed and treated.

Depression often coexists with eating disorders such as anorexia nervosa, bulimia nervosa and others, especially among women. Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia and generalized anxiety disorder (GAD), also sometimes accompany depression.^15,16

Women are more prone than men to having a coexisting anxiety disorder.¹⁷ Women suffering from PTSD, which can result after a person endures a terrifying ordeal or event, are especially prone to having depression.

Although more common among men than women, alcohol and substance abuse or dependence may occur at the same time as depression.^17,15

Research has indicated that among both sexes, the coexistence of mood disorders and substance abuse is common among the U.S. population.¹⁸

Depression also often coexists with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, Parkinson's disease, thyroid problems and multiple sclerosis, and may even make symptoms of the illness worse.¹⁹

Studies have shown that both women and men who have depression in addition to a serious medical illness tend to have more severe symptoms of both illnesses. They also have more difficulty adapting to their medical condition, and more medical costs than those who do not have coexisting depression. Research has shown that treating the depression along with the coexisting illness will help ease both conditions.²⁰

How does depression affect adolescent girls?
Before adolescence, girls and boys experience depression at about the same frequency.¹³ By adolescence, however, girls become more likely to experience depression than boys.

Research points to several possible reasons for this imbalance. The biological and hormonal changes that occur during puberty likely contribute to the sharp increase in rates of depression among adolescent girls. In addition, research has suggested that girls are more likely than boys to continue feeling bad after experiencing difficult situations or events, suggesting they are more prone to depression.²¹

Another study found that girls tended to doubt themselves, doubt their problem-solving abilities and view their problems as unsolvable more so than boys. The girls with these views were more likely to have depressive symptoms as well.

Girls also tended to need a higher degree of approval and success to feel secure than boys.²²

Finally, girls may undergo more hardships, such as poverty, poor education, childhood sexual abuse, and other traumas than boys.

One study found that more than 70 percent of depressed girls experienced a difficult or stressful life event prior to a depressive episode, as compared with only 14 percent of boys.²³

How does depression affect older women?
As with other age groups, more older women than older men experience depression, but rates decrease among women after menopause.¹³ Evidence suggests that depression in post-menopausal women generally occurs in women with prior histories of depression. In any case, depression is NOT a normal part of aging.

The death of a spouse or loved one, moving from work into retirement, or dealing with a chronic illness can leave women and men alike feeling sad or distressed.

After a period of adjustment, many older women can regain their emotional balance, but others do not and may develop depression. When older women do suffer from depression, it may be overlooked because older adults may be less willing to diskuss feelings of sadness or grief, or they may have less obvious symptoms of depression.

As a result, their practitioners may be less likely to suspect or spot it.

For older adults who experience depression for the first time later in life, other factors, such as changes in the brain or body, may be at play. For example, older adults may suffer from restricted blood flow, a condition called ischemia.

Over time, blood vessels become less flexible. They may harden and prevent blood from flowing normally to the body's organs, including the brain. If this occurs, an older adult with no family or personal history of depression may develop what some doctors call "vascular depression."

Those with vascular depression also may be at risk for a coexisting cardiovascular illness, such as heart disease or a stroke.²⁴

How do men experience depression?
Men often experience depression differently than women and may have different ways of coping with the symptoms.

Men are more likely to acknowledge having fatigue, irritability, loss of interest in once–pleasurable activities, and sleep disturbances, whereas women are more likely to admit to feelings of sadness, worthlessness and/or excessive guilt.^12,13

Men are more likely than women to turn to alcohol or drugs when they are depressed, or become frustrated, diskouraged, irritable, angry and sometimes abusive. Some men throw themselves into their work to avoid talking about their depression with family or friends, or engage in reckless, risky behavior.

And even though more women attempt suicide, many more men die by suicide in the Australia.¹⁴

How do older adults experience depression?
Depression is not a normal part of aging, and studies show that most seniors feel satisfied with their lives, despite increased physical ailments. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief.¹⁵

In addition, older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what some practitioners call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression.

Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body's organs, including the brain. Those with vascular depression may have, or be at risk for, a co–existing cardiovascular illness or stroke.¹⁶

Although many people assume that the highest rates of suicide are among the young, older white males age 85 and older actually have the highest suicide rate.

Many have a depressive illness that their practitioners may not detect, despite the fact that these suicide victims often visit their practitioners within one month of their deaths.¹⁷

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both.¹⁸ Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults.¹⁹

Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.^{20, 21}

How do children and adolescents experience depression?
Scientists and practitioners have begun to take seriously the risk of depression in children. Research has shown that childhood depression often persists, recurs and continues into adulthood, especially if it goes untreated. The presence of childhood depression also tends to be a predictor of more severe illnesses in adulthood.²²

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to accurately diagnose a young person with depression.

Before puberty, boys and girls are equally likely to develop depressive disorders. By age 15, however, girls are twice as likely as boys to have experienced a major depressive episode.²³

Depression in adolescence comes at a time of great personal change–when boys and girls are forming an identity distinct from their parents, grappling with gender issues and emerging sexuality, and making decisions for the first time in their lives.

Depression in adolescence frequently co–occurs with other disorders such as anxiety, disruptive behavior, eating disorders or substance abuse. It can also lead to increased risk for suicide. ^{22, 24}

A US National Institute of Mental Health funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option.²⁵ Other researchers around the world are developing and testing ways to prevent suicide in children and adolescents, including early assessment, diagnosis and treatment, and a better understanding of suicidal thinking.

How can I help a friend or relative who is depressed?
If you know someone who is depressed, it affects you too.

The first and most important thing you can do to help a friend or relative who has depression is to help him or her get an appropriate multi-disorder assessment leading to an acurate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with him or her to see the practitioner.

Encourage him or her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

To help a friend or relative:

• Offer emotional support, understanding, patience and encouragement.
• Engage your friend or relative in conversation, and listen carefully.
• Never disparage feelings your friend or relative expresses, but point out realities and offer hope.
• Never ignore comments about suicide, and report them to your friend's or relative's therapist or practitioner.
• Invite your friend or relative out for walks, outings and other activities. Keep trying if he or she declines, but don't push him or her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure.
• Remind your friend or relative that with time and treatment, the depression will lift.

How can I help myself if I am depressed?
If you have depression, you may feel exhausted, helpless and hopeless. It may be extremely difficult to take any action to help yourself. But it is important to realize that these feelings are part of the depression and do not accurately reflect actual circumstances.

As you begin to recognize your depression and begin treatment, negative thinking will fade.

To help yourself:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed. Participate in religious, social or other activities.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Where can I go for help?
If you are unsure where to go for help, ask your Family Physician in the first instance but be aware that not all Family Physicians have the same interest in, or knowledge of behavioral health issues and most have limited time. 

It is important that you take the time to find a Family Physician with a particular interest in behavioral health who understands that the best care is usually delivered when a collaborating team of healthcare providers (behavioral health nurse, Family Physician, psychologist and the problem becomes more acute, a psychiatrist) support and respect each other's work and merge their efforts.  

The single most important thing you can do is find good quality professionals who understand the importance of multi-disorder assessment and a team approach to finding the best treatment options that will work for you.

Mental Health Resources:

• Mental health specialists, such as psychiatrists, psychologists, social workers, or behavioral health counselors
• Health maintenance organizations
• Community behavioral health centers
• Hospital psychiatry departments and outpatient clinics
• Mental health programs at universities or medical schools
• State hospital outpatient clinics
• Family services, social agencies or clergy
• Peer support groups
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies
• You can also check the phone book under "behavioral health," "health," "social services," "hotlines," or "general practitioners" for phone numbers and addresses. An emergency room practitioner also can provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?
If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately.

• Call your Family Physician.
• Call 000 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
• Call the toll-free, 24-hour Lifeline on 13 11 14 to talk to a trained counselor.
• Make sure you or the suicidal person is not left alone.