Depression

What is depression?

The word depressed is a common everyday word. People might say "I'm depressed" when in fact they mean "I'm fed up because I've had a row, or failed an exam, or lost my job", etc. These ups and downs of life are common and normal. Most people recover quite quickly. True, clinical depression is a mood disorder, which means you have a low mood and other symptoms each day for at least two weeks. Symptoms can also become severe enough to interfere with normal day-to-day activities.

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Depression symptoms

Many people know when they are depressed. However, some people do not realise when they are depressed. They may know that they are not right and are not functioning well but don't know why. Some people might think that they have a physical illness - for example, if they lose weight. However physical symptoms can be caused by depression.

There is a set of symptoms that are associated with depression and help to clarify the diagnosis. Signs and symptoms of depression include:

Core symptoms

• Persistent sadness or low mood. This may be with, or without, a tendency to cry.
• Marked loss of interest or pleasure in activities, even for activities that you normally enjoy.

Other common symptoms

• Disturbed sleep compared with your usual pattern. This may be difficulty in getting off to sleep, or waking early and being unable to get back to sleep. Sometimes it is sleeping too much.
• Change in appetite. This is often a poor appetite and weight loss. Sometimes the reverse happens with comfort eating and weight gain.
• Tiredness (fatigue), or loss of energy.
• Agitation or slowing of movements.
• Poor concentration or indecisiveness. For example, you may find it difficult to read, work, etc. Even simple tasks can seem difficult.
• Feelings of worthlessness, or excessive or inappropriate guilt.
• Recurrent thoughts of death. This is not usually a fear of death, more a preoccupation with death and dying. For some people despairing thoughts such as "life's not worth living" or "I don't care if I don't wake up" are common. Sometimes these thoughts progress into thoughts about, and even plans for, suicide.

Many people with depression say that their symptoms are often worse first thing each day. Also with depression, it is common to develop physical symptoms such as headaches, the sensation of having a 'thumping' heart (palpitations), chest pains and general aches. Some people consult a doctor at first because they have a physical symptom such as chest pains. They are concerned that they may have a physical problem such as a heart condition when it is actually due to depression. Depression is in fact quite a common cause of physical symptoms. But, the opposite is also true. That is, people with serious physical conditions are more likely than average to develop depression.

Some people with severe depression also develop delusions and/or hallucinations. These are called psychotic symptoms. A delusion is a false belief that a person has, and most people from the same culture would agree that it is wrong - for example, a belief that people are plotting to kill you or that there is a conspiracy about you. Hallucination means hearing, seeing, feeling, smelling, or tasting something that is not real.

How is depression diagnosed?

An episode of depression is usually diagnosed if you have depressed mood or reduced interest in activities occurring most of the day, nearly every day, for at least two weeks, accompanied by other symptoms such as:

• Reduced ability to concentrate and sustain attention or marked indecisiveness.
• Beliefs of low self-worth or excessive or inappropriate guilt.
• Hopelessness about the future.
• Recurrent thoughts of death or suicidal ideation or evidence of attempted suicide.
• Significantly disrupted sleep or excessive sleep.
• Significant changes in appetite or weight.
• Feeling agitated and restless, or feeling very sluggish with reduced body movement and slowing of thought processes.
• Reduced energy or fatigue.

How common is depression?

Depression is common but many people don't admit to it. Some people feel there is a stigma attached, or that people will think they are weak. Depression is one of the most common illnesses that GPs deal with.

About 5 in 100 adults experience depression every year. Sometimes it is mild or lasts just a few weeks. However, an episode of depression serious enough to require treatment occurs in about 1 in 4 women and 1 in 10 men at some point in their lives. Some people have two or more episodes of depression at various times in their lives.

Depression severity

The severity of depression can vary from person to person. Severity is generally divided as follows:

Severe depression

You would normally have most or all of the nine symptoms listed above. Also, symptoms markedly interfere with your normal functioning.

Moderate depression

You would normally have more than the five symptoms that are needed to make the diagnosis of depression. Also, symptoms will usually include both core symptoms. Also, the severity of symptoms or impairment of your functioning is between mild and severe.

Mild depression

You would normally have five of the symptoms listed above that are required to make the diagnosis of depression. However, you are not likely to have more than five or six of the symptoms. Also, your normal functioning is only mildly impaired.

Subthreshold depression

You have fewer than the five symptoms needed to make a diagnosis of depression. So, it is not classed as depression. But, the symptoms you do have are troublesome and cause distress. If this situation persists for more than two years it is sometimes called dysthymia.

However, in its clinical guideline for depression, the National Institute for Health and Care Excellence (NICE) describes episodes of depression as being either less severe or more severe:

• Less severe depression includes subthreshold and mild depression.
• More severe depression includes moderate and severe depression.

What causes depression?

The exact cause is not known. Anyone can develop depression. Some people are more prone to it and it can develop for no apparent reason. You may have no particular problem or worry, but depression symptoms can develop quite suddenly. So, there may be some genetic factor involved that makes some people more prone than others to depression. 'Genetic' means that the condition is passed on through families.

An episode of depression may also be triggered by a life event such as a relationship problem, bereavement, redundancy, illness, etc. In many people it is a mixture of the two. For example, the combination of a mild low mood with some life problem, such as work stress, may lead to a spiral down into depression.

Women tend to develop depression more often than men. Particularly common times for women to become depressed are after childbirth (postnatal depression) and the menopause.

Depression and physical conditions

Although the cause of depression is not clear, there are some useful things to remember about depression in relation to physical conditions.

• Depression is more common in people who are known to have certain physical conditions.
• The diagnosis of depression is sometimes confused with some undiagnosed diseases caused by physical conditions.

Known physical conditions

Depression is more common than average in people coping with serious or severe physical diseases. Although the treatment of the physical disease may take priority, the treatment of depression is also useful to improve overall well-being.

Undiagnosed physical conditions

Various physical conditions may at first seem to mimic depression. Doctors aim to be on the lookout for these diseases and may order tests to rule them out if one is suspected. Perhaps the most common examples are:

• An underactive thyroid gland (hypothyroidism) - can make you feel quite low, weepy and tired. A blood test can diagnose this.
• An underactive pituitary gland (hypopituitarism) - the pituitary gland is just under the brain. It makes various hormones which have various actions. Sometimes one hormone can be deficient; sometimes more than one. There are various symptoms that can develop. These include loss of sex drive, sexual problems, infertility, uncontrollable weight gain and feeling low, depressed and even suicidal. Blood tests can help to diagnose hypopituitarism. There are various causes of hypopituitarism, including head injury.
• Head injury - even a relatively mild one, even many years ago. For example, studies have shown that rates of suicide (presumably related to depression) are more common than average in people who have previously had a head injury. The reason for this is not fully understood. However, one factor that may be significant in some cases is that a head injury may result in hypopituitarism, as discussed above.
• Polymyalgia rheumatica - this condition mainly affects older people. Typical symptoms include stiffness, pain, aching, feeling depressed and tenderness of the large muscles around the shoulders and upper arms. Feeling depressed can be the first main symptom before the other symptoms predominate.
• Early dementia - is sometimes confused with depression.
• Certain medicines - both prescribed and street (illicit) drugs - can cause side-effects which may mimic depression.

The rest of this leaflet is about depression of unknown cause that is not associated with any physical condition.

What are the treatment options for depression?

In general, treatments are divided into those used for mild depression and those used for moderate and severe depression.

What if I don't have any treatment?

Most people with depression will get better without treatment. However, this may take several months or even longer. (The average length of an episode of depression is 6-8 months.) Meanwhile, living with depression can be difficult and distressing (and also for your family and friends). Relationships, employment, etc, may be seriously affected. There is also a danger that some people turn to alcohol or illegal drugs. Some people think of suicide. Therefore, many people with depression opt for treatment.

How to treat depression

The following are the commonly used treatment options for people with less severe depression. Some people prefer one type of treatment to another. So, personal preference for the type of treatment used should be taken into account when discussing the best treatment for yourself with your doctor.

• Guided self-help: this involves printed or digital materials that include structured cognitive behavioural therapy (CBT), structured behavioural activation (BA), problem-solving, and materials to help you understand your mental health difficulties.
• Group cognitive behavioural therapy (CBT): this usually consists of eight regular sessions, with eight people in the group. Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact, and teaches coping skills to deal with things in life differently.
• Group behavioural activation (BA): usually consists of eight regular sessions, with eight people in the group. Focuses on identifying the link between your activities and your mood. Helps you to recognise patterns and plan practical changes that reduce avoidance and that focus on behaviours that are linked to improved mood.
• Individual CBT or individual BA: usually consists of eight regular sessions, although additional sessions may be needed if you also have other mental or physical health problems or complex social needs.
• Group exercise: uses a physical activity programme specifically designed for people with depression. Usually consists of more than one session per week for 10 weeks. Usually eight participants in the group and includes moderate-intensity aerobic exercise. Exercise improves depressive and anxiety symptoms. See also the separate leaflet called Exercise and Physical Activity.
• Group mindfulness and meditation: uses a programme such as mindfulness-based cognitive therapy specifically designed for people with depression. Usually consists of eight regular sessions, with 8-15 participants in the group. Focus is on concentrating on the present, observing and sitting with thoughts and feelings and bodily sensations, and breathing exercises.
• Interpersonal psychotherapy (IPT): usually consists of 8-6 regular sessions, although additional sessions may be needed if you also have other mental or physical health problems or complex social needs. Focus is on identifying how interpersonal relationships or circumstances are related to feelings of depression, exploring emotions and how you respond to others.
• Antidepressant medication: selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants and are usually taken for at least six months (including after your symptoms resolve). Symptoms such as low mood, poor sleep, poor concentration, etc, are often eased with an antidepressant. This may then allow you to function more normally and increase your ability to deal with any problems or difficult circumstances.
• Counselling: this usually consists of eight regular sessions, although additional sessions may be needed for people with comorbid mental or physical health problems or complex social needs, or to address residual symptoms. Focus is on emotional processing and finding emotional meaning, to help people find their own solutions and develop coping mechanisms.
• Short-term psychodynamic psychotherapy (STPP): usually consists of 8-16 regular sessions, although additional sessions may be needed if you also have other mental or physical health problems or complex social needs. Focus is on recognising difficult feelings in significant relationships and stressful situations, and identifying how patterns can be repeated.

Couple therapy. This may be an option for people who have a regular partner and where the relationship contributes to the depression, or, where involving the partner is considered to be of potential useful benefit.

How to treat severe depression

More severe depression is often treated with a combination of CBT and antidepressant medication.

The options for treating more severe depression are otherwise similar to less severe depression but the treatments used are provided for longer periods of time.

Other treatments

Electroconvulsive therapy (ECT) may be advised if you have severe depression which has not improved with other treatments.

St John's wort for depression

This is not advised. St John's wort (hypericum) is a herbal antidepressant that you can buy, without a prescription, from pharmacies. It became a popular treatment for depression. However, national guidelines for depression do not advise that you take this because:

• It is not clear how well it works. Although some studies suggest that it may help depression, other studies have failed to confirm this.
• Side-effects sometimes occur. (Some people think that because St John's wort is 'natural' then it is totally safe. This is not true. It contains many chemicals which sometimes cause problems.)
• It may react with other medicines that you may take. Sometimes the reactions can cause serious problems. For example, you should not take St John's wort if you are taking warfarin, ciclosporin, oral contraceptives, anticonvulsants, digoxin, theophylline, or certain anti-HIV medicines. Also, you should not take it at the same time as certain other prescribed antidepressants.

How to deal with depression

• Don't bottle things up and 'go it alone'. Try to tell people who are close to you how you feel. It is not weak to cry or admit that you are struggling.
• Don't despair - most people with depression recover. It is important to remember this.
• Do try to distract yourself by doing other things. Try doing things that do not need much concentration but can be distracting, such as watching TV. Radio or TV is useful late at night if sleeping is a problem.
• Do eat regularly, even if you do not feel like eating. Try to eat a healthy diet.
• Don't drink too much alcohol. Drinking alcohol is tempting to some people with depression, as the immediate effect may seem to relieve the symptoms. However, drinking heavily is likely to make your situation worse in the long run. Also, it is very difficult either to assess or to treat depression if you are drinking a lot of alcohol.
• Don't make any major decisions whilst you are depressed. It may be tempting to give up a job or move away to solve the problem. If at all possible you should delay any major decisions about relationships, jobs, or money until you are well again.
• Do tell your doctor if you feel that you are getting worse, particularly if suicidal thoughts are troubling you. See the separate leaflet called Dealing with Suicidal Thoughts.
• Sometimes a spell off work is needed. However, too long off work might not be so good, as dwelling on problems and brooding at home may make things worse. Getting back into the hurly-burly of normal life may help the healing process when things are improving. Each person is different and the ability to work will vary.
• Sometimes a specific psychological problem can cause depression but some people are reluctant to mention it. One example is sexual abuse as a child, leading to depression or psychological difficulties as an adult. Tell your doctor if you feel something like this is the root cause of your depression. Counselling may be available for such problems.

Understanding that your symptoms are due to depression, may help you to accept that you are ill and need help. Some people ask: "Am I going mad?" It may be a relief to know that you are not going mad and that the symptoms you have are common and have been shared by many other people.

You may 'bottle up' your symptoms from friends and relatives. However, if you are open about your feelings with close family and friends, it may help them to understand and help.

Will it happen again?

A one-off episode of depression at some stage in life is common. However, some people have two, three, or more episodes of depression. You can have treatment for each episode. But, if you are prone to repeated episodes of depression, options that may be considered by you and your doctor include the following:

• To take an antidepressant long-term to help prevent depression from returning.
• Mindfulness-based cognitive therapy. This may be advised (if available) for people who are currently well but have had three or more episodes of depression. This therapy is a specialist type of talking treatment. There is good evidence that it can help to prevent depression returning. The therapy is typically done in groups of 8 to 15 people. It consists of weekly two-hour meetings over about eight weeks. There are then four follow-up sessions in the 12 months after the end of treatment.

Conditions related to depression

Postnatal depression

Some women develop depression just after having a baby. See the separate leaflet called Postnatal Depression.

Bipolar disorder

In some people, depression can alternate with periods of elation and overactivity (mania or hypomania). This is called bipolar disorder (sometimes called manic depression). Treatment tends to include mood stabilising medicines such as lithium. See the separate leaflet called Bipolar Disorder.

Seasonal affective disorder

Sometimes depression can be triggered by certain times of the year such as Christmas, in the new year or summer. Some people develop recurrent depression in the winter months only. This is called seasonal affective disorder (SAD). See the separate leaflet called Seasonal Affective Disorder.

Other mental health problems

Depression sometimes occurs at the same time as other mental health problems:

• People with anxiety, panic disorder and personality disorders quite commonly also develop depression. As a rule, depression should be treated first, followed by treatment of the other disorder. In particular, anxiety will often improve following treatment of depression.
• Eating disorders such as anorexia and bulimia may accompany depression. In this situation the eating disorder is usually the main target of treatment.