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In this chapter we talk about major depressive disorder, which is only one form of depressive illness. If you are not sure that you have a major depressive disorder, this book may help to answer your questions and give you information. This is designed as a patient’s guide. You may want to:
The information in this book is based on evaluation of research studies. Other treatments for depression that are available, while effective for some people, have not been carefully studied.
Who gets depressed?
Major depressive disorder--often referred to as depression-- is a common illness that can affect anyone. About 1 in 20 Americans (over 11 million people) get depressed every year. Depression affects twice as many women as men.
What is depression?
Depression is not just “feeling blue” or “down in the dumps.” It is more than being sad or feeling grief after a loss. Depression is a medical disorder (just like diabetes, high blood pressure, or heart disease are medical disorders) that day after day affects your thoughts, feelings, physical health, and behaviors.
Depression may be caused by many things, including:
Certain life conditions (such as extreme stress or grief), may bring on a depression or prevent a full recovery. In some people, depression occurs even when life is going well. Depression is not your fault. It is not a weakness. It is a medical illness. Depression is treatable.
How will I know if I am depressed?
People who have major depressive disorder have a number of symptoms nearly every
day, all day, for at least 2 weeks. These always include at least one of the following:
You may also have at least three of the following symptoms:
With depression, there are often other physical or psychological symptoms, including:
What should I do if I have these symptoms?
Too often people do not get help for their depression because they don’t recognize the
symptoms, have trouble asking for help, blame themselves, or don’t know that treatments are available. Family practitioners, clinics, or health maintenance organizations are often the first places that people go for help. These health care providers will:
If you do not have a regular health care provider, contact your local health department, community mental health clinic, or hospital. University medical centers also provide treatment for depression.
How will treatment help me?
Treatment reduces the pain and suffering of depression. Successful treatment removes all of the symptoms of depression and returns you to your normal life. The earlier you get treatment for your depression, the sooner you will begin to feel better. As with other medical illnesses, the longer you have the depression before you seek treatment, the more difficult it can be to treat.
Most people who are treated for depression feel better and return to daily activities in several weeks. Because it takes several weeks for treatment to work fully, it is important to get treatment early before your depression gets worse.
As with any medical condition, you may have to try one or two treatments before finding the best one. It is important not to get discouraged if the first treatment does not work. In almost every case, there is a treatment for the depression that will work for you.
What type of treatment will I get?
The major treatments for depression are:
Thoughts of suicide or death are often a part of depression. If you have these thoughts, tell someone you trust now. Ask them to help you find professional help right away. Once your depression is properly treated, these thoughts will go away.
In some cases of depression, other treatments, such as electroconvulsive therapy (ECT) and light therapy, are also useful.
Who should see a mental health specialist?
Many people with depression can be successfully treated by their general health care provider. However, some people need specialized treatment because the first treatment does not work, because they need a combination of treatments, or because the depression is severe or it lasts a long time. Many times, a second opinion or consultation is all that is needed. If the mental health specialist provides treatment, it is most often on an outpatient basis (not in the hospital). If you think you need to see a mental health specialist, tell your health care provider, or contact one of the mental health organizations listed in this chapter.
The health care providers listed above can refer you to one of the health care providers specializing in mental health listed below:
Psychiatrist—A physician who specializes in the diagnosis and treatment of mental or psychiatric disorders.
Psychologist—A person with a doctoral degree (Ph.D. or Psy.D.) in psychology and training in counseling, psychotherapy, and psychological testing.
Social Worker—A person with a degree in social work. A social worker with a master’s degree often has specialized training in counseling.
Psychiatric Nurse Specialist—A registered nurse (R.N.) usually with a master’s degree in psychiatric nursing who specializes in treating mental or psychiatric disorders.
When someone is depressed, that person has several symptoms nearly every day, all day, that last at least 2 weeks.
You can use the chart to check off any symptoms you have had for 2 weeks or more.
Loss of interest in things you used to enjoy, including sex*
Feeling sad, blue, or down in the dumps*
Feeling slowed down or restless and unable to sit still
Feeling worthless or guilty
Changes in appetite or weight loss or gain
Thoughts of death or suicide; suicide attempts
Problems concentrating, thinking, remembering, or making decisions
Trouble sleeping or sleeping too much
Loss of energy or feeling tired all of the time
Other symptoms include:
Headaches
Other aches and pains
Digestive problems
Sexual problems
Feeling pessimistic or hopeless
Being anxious or worried
If you have had five or more of these symptoms including at least one of the first two symptoms marked with an asterisk ( * ) for at least 2 weeks, you may have major depressive disorder. See your health care provider for diagnosis. If you have some depressive symptoms, you should also tell your health care provider.
Sometimes a few symptoms can go on to become major depressive disorder. Some forms of depression are mild, but persistent or chronic. Chronic symptoms of depression also need treatment.
Some people with depression have mood cycles. They have terrible “lows”(depression) and inappropriate “highs” (mania) that can last from several days to months. In between the highs and lows, they feel completely normal. This condition is called bipolar disorder or manic-depressive disorder.
Bipolar disorder affects about 1 in 100 people. Just as eye or hair color are inherited, bipolar disorder in most cases is inherited. It can also be caused by other general medical problems, such as head injury or neurologic or other general medical conditions.
You can use this list to learn the symptoms of mania and to check off any you might have.
| Feeling unusually “high,” euphoric, or irritable* | |
| Needing less sleep | |
| Talking a lot or feeling that you can’t stop talking | |
| Being easily distracted | |
| Having lots of ideas go through your head very quickly at one time. | |
| Doing things that feel good but have bad effects (spending too much money, inappropriate sexual activity, foolish business investments) | |
| Having feelings of greatness | |
| Making lots of plans for activities (at work, school, or socially) or feeling that you have to keep moving |
If you have had four of these symptoms at one time for at least 1 week, including the first symptom marked with an asterisk(*), you may have had a manic episode. Tell your health care provider about the episode. There are effective treatments for this form of depression.
Major depressive disorder is not caused by any one factor. It is probably caused by a combination of biological, genetic, psychological, and other factors. Certain life conditions (such as extreme stress or grief) may bring out a natural psychological or biological tendency toward depression. In some people, depression occurs even when life is going well.
Drinking too much alcohol or using drugs can sometimes cause depression. When the drug and alcohol use is stopped, the depression usually goes away. Talk to your health care provider if you have a problem with drugs or alcohol. It can be treated.
Remember, major depressive disorder is not caused by personal weakness, laziness, or lack of will power. It is a medical illness that can be treated.
Here are some examples of the kinds of things your care provider will ask you about your health. You can write down the information in space provided.
You can help your health care provider diagnose and treat you by giving as much information as possible about your health. You can use the chart on these pages to write down some of that information. Information that you share with a health care provider is confidential.
If your depression is causing you to have a hard time talking and remembering, take a family member or friend along on your first visit to help.
A general medical history, physical examination, and basic laboratory tests can help find out if a general medical disorder is the cause of your depression. About 10 to 15 percent of all depressions are caused by general medical illness (such as thyroid disease, cancers, or neurologic diseases) or medicines. Once the condition is treated or the medicines are changed or adjusted, the depression will usually go away.
If you have a general medical illness and feel depressed, it is important to tell your health care provider. Sometimes depression is a reaction to a life-threatening condition. Getting help during a difficult time in your life may help you to cope with your general medical illness.
If your first episode of major depressive disorder occurred after age 40, a very thorough medical evaluation is important.
In the treatment section of this book, the terms severe, moderate, and mild depression are used. In general. . .
For each type of depression there is a treatment that works best. You should talk with your health care provider about your depression and the best treatment for you.
The aim of acute treatment is to remove the symptoms of depression until you feel well. Continuation treatment (continuing the treatment for some time even after you are well) is important because it keeps the episode of depression from coming back. Depending on the type of treatment you have, your chances of staying well for 6 months on continuation treatment are extremely good.
In cases of recurrent depression (three or more episodes), a third step, called maintenance treatment, is used to treat the depression. In maintenance treatment, you stay on the treatment for a longer period of time. The purpose of maintenance treatment is to prevent a recurrence of the depression. With maintenance treatment, the chances of staying well are also extremely good.
For severe depression, research studies show that medicine is very effective. Psychotherapy has not been well studied for the more severe forms of depression.
Treatment for depression works gradually over several weeks. With medicine, most people see some benefits by 3 or 4 weeks; with psychotherapy alone, it can sometimes take longer. There is a very good chance that your first treatment will work well for you. If treatment is not effective after a certain amount of time, it can be changed or adjusted. There are other treatments to try, and your chances for effective treatment are still very good.
If at any time you are worried about your treatment or you don’t think that things are going well, tell someone about your concerns. You can:
Health care providers are interested in your concerns and will help you. This may mean getting a second opinion or even finding another health care provider.
There are many different types of antidepressant medicines that can be used to treat depression. Each of these types of medicine work a little differently. Your symptoms, medical history, and family history often give clues about the best medicine for you. Still, it may take some time to find the one that works best for you and has the least side effects. Together, you and your health care provider will find the exact type and amount of medicine that you need.
Antidepressant medicines are not addictive or habit forming. They work in severe depression and may be useful in mild to moderate depression.
Many people begin to feel the effects of medicine even in the first few weeks of treatment. After about 6 weeks, more than half of the people who begin antidepressant medicine will feel more like their usual self.
At the beginning of treatment, your health care provider will want to see you more often (possibly every week). The purpose of these visits is to check the dosage (how much and how often you take the medicine), to watch for side effects (problems caused by the medicine), and to see how the treatment is working on your depression.
Once you begin to feel better, you probably will visit the health care provider less often. In continuation treatment, you will probably visit your health care provider every month or two. In maintenance treatment, visits are usually every 2 to 3 months.
You will get the most help from your treatment if you do five things:
Keep all of your appointments whether you are feeling better or worse. If you are taking antidepressant medicines, you must keep all of your appointments to check the dosage and watch for side effects.
Ask questions. Talk to your health care provider if you have concerns about the medicine. The answer to some of your questions may help you and your health care provider to choose the treatment that is best for you personally. Remember: There is no such thing as a “dumb” question when it comes to your health.
Name of medicine:
Take your medicine as directed, even when you begin to feel better. It is important to continue to take the medicine in order to keep feeling well. You may want to write down the name of the medicine you are taking.
Tell your health care provider right away about any side effects you have. Even though all medicines have some side effects, not all people get them. Some patients have different side effects than others. With antidepressant medicines, up to half of the people have some side effects early in treatment (in the first 4 to 6 weeks). Side effects are usually not a problem after that. For a small number of people, side effects are bad enough to stop the medicine.
The side effects you might get depend on many things. These are:
If side effects are a problem for you, there are a number of things your health care provider can do. Changes can be made in:
Changing medicine is a complicated medical decision. It is dangerous to make changes in your medicine on your own!
Here are some common side effects of antidepressant medicines:
More serious side effects are rare. As with minor side effects, they usually happen in the first few weeks of treatment. They include difficulty passing urine, heart trouble, sexual problems, seizures, fainting, or other effects. Both the common and rare side effects are nearly always treatable.
If you are having side effects, call your health care provider. Do not wait for the next appointment.
About 1 in 10 people who have a close relative with bipolar disorder can develop manic symptoms in the first few weeks of taking the medicine. Only a very small number (1 or 2 out of 100) of people without a relative with bipolar disorder experience manic symptoms when taking antidepressant medicine. An early sign that manic symptoms may be coming is that you feel that you have a lot of energy or feel very “high” or euphoric. Tell your health care provider about these changes right away.
Tell your health care provider how the medicine is working. One way to know how the medicine is working is to keep a record of your symptoms. If the medicine is not working for you (your symptoms are getting worse or not getting better), your health care provider may recommend a blood test to see whether you are getting the right amount of medicine in your body.
There are many things that can be done if the medicine is not working. These are:
Continuation treatment. Once you are feeling better for awhile, you and your health care provider will decide if this episode of depression has ended. In most cases, you should continue to take the antidepressant medicine for several months. Research clearly shows that continuation treatment with medicine helps prevent a relapse (a return) of the depressive episode.
After 4 to 9 months of continuation treatment, if you continue to feel good, you have recovered from this episode of depression. If you have had only a single episode of depression, continuation treatment can be stopped with a good chance that you will remain well. Nearly all patients who are on continuation treatment will stay well during that time.
Maintenance treatment. Some people with depression need maintenance (long-term) treatment. If you have had at least three episodes of depression or if you have bipolar disorder, you will need maintenance treatment to stay well. Research clearly shows that maintenance treatment with medicine prevents a new episode of depression. Some antidepressant medicines have been used by patients for 30 or more years with no bad effects.
Before starting maintenance treatment, you and your health care provider should discuss its costs and benefits.
The aim of acute treatment with psychotherapy alone is to remove all symptoms of depression and return you to your normal life. In psychotherapy, you work with a qualified health care provider (therapist) who listens, talks, and helps you solve your problems. Psychotherapy is usually brief and often has a time limit (for example, 8 to 20 visits).
Psychotherapy can be individual (only you and a therapist); it can be group therapy (with a therapist, you, and other people with similar problems); or it can be family or marriage therapy (with a therapist, you, and family members, loved ones, or spouse).
Your health care provider will help you decide if psychotherapy is the right treatment for your depression.
Three psychotherapies have been most well studied for their effectiveness in reducing symptoms of major depressive disorder. They are:
Psychotherapy alone is not recommended as the only treatment for severe depression or for bipolar (manic-depressive) disorder. Medicine is needed for these types of depression.
If you choose psychotherapy you need to:
The cognitive, behavioral, and interpersonal therapies usually work gradually. Although psychotherapy may begin to work right away, for some people it may take 8 to 10 weeks to show a full effect. More than half of the patients with mild to moderate forms of major depression respond well to psychotherapy.
As with medicine, it is important to remember that people can react differently to similar treatments. While many people find psychotherapy effective, others do not. This usually means that another treatment is needed.
If you do not feel any better at all after 6 weeks, or if you are not completely well by 12 weeks, talk to your health care provider about other treatments.
Continuation psychotherapy. If your depression gets better with psychotherapy, you and your health care provider can decide if your therapy should continue and for how long.
Maintenance psychotherapy. In general, maintenance (long-term) psychotherapy by itself is not recommended unless there are reasons, such as pregnancy or severe side effects, that keep you from taking medicine. While maintenance psychotherapy does not prevent another episode of depression, some research suggests that it can delay a recurrence.
In combined treatment, medicine is used to treat the symptoms of depression, and psychotherapy is used to help with ways in which depression causes problems in your life. Some people find that combining treatment is very helpful. With combined treatment, more than half of the patients feel better after 6 to 8 weeks. Combined treatment may be most helpful for longer lasting depression, for those with symptoms between episodes, or for those who do not respond fully to medication or psychotherapy alone.
Most depressions, even severe depressions, can be treated completely with medicine, psychotherapy, or the combination of both. Electroconvulsive therapy (ECT) works to remove the symptoms of depression. It is mostly used for severely depressed patients who have not responded to antidepressant medicines. It can also be used for patients who are severely depressed and have other severe general medical illnesses. ECT is much safer than in years past. General anesthesia and special muscle relaxing medicines are used to prevent physical harm and pain during the ECT. The choice of ECT as a treatment and the possible side effects should be discussed with a psychiatrist. As with other treatments, the psychiatrist will monitor the ECT treatment and check for side effects.
In light therapy, a special kind of light called broad-spectrum light is used to give people the effect of having a few extra hours of daylight each day. Specially made light box or light visors are used to provide this light Light therapy may help people who have mild or moderate seasonal depression. This treatment should only be given by a specialist until it has been studied more thoroughly.
When you are depressed, it is important to:
There is some evidence in milder cases of depression that exercise can be a helpful addition to treatment.
When people have major depressive disorder, they often have difficulty at work, school, and with family members. With treatment, almost everyone returns to their normal life. Some jobs (where the safety of others is involved) require that you report treatment for medical illnesses (including depression). You and your health care provider should talk about how and what to tell your supervisor, teacher, or friends.
Ask your friends for their support, understanding, and patience during your depression. It may be helpful to talk to your friends about your feelings and treatment and to spend time with friends in social activities. Keep the name and phone number of people that you can talk to and to ask to help you. Some people with depression find it difficult to be with others during this time. If you feel this way, do whatever lifts your mood and makes you feel better. If you find yourself alone and unable to be with others, tell your health care provider. Many people find that family members are very supportive and helpful, especially those who have received education about depression.
Parents often worry about whether depression is inherited. Most children
of people with depression will not get this illness. Overall, research shows
that only about 1 in 7 children with one parent who has had several episodes
of major depressive disorder or bipolar disorder will develop major depressive
disorder. Another 1 in 7 children with one parent who has bipolar disorder
will develop bipolar disorder. If you have questions about your child’s mental
health talk to a health care provider.
The treatments for major depressive disorder discussed in detail in this book are:
How well each of these treatments works depends on the type of depression, how severe the depression is, how long you have been depressed, how you as an individual may react to treatment, and other factors. The risks and benefits described below are based on current medical knowledge using studies of large numbers of depressed patients and expert opinion.
| Treatments | Antidepressant medicine* | Pyschotherapy | Antidepressant medicine* com bined with psychotherapy |
|---|---|---|---|
| Chances that treatment will work (benefit) | 50 to 65 percent | 45 to 60 percent | 50 to 65 percent |
| Chances for immediate side effects or complications (risks) | Minor side effects: 50 percent. Side effects bad enough to stop treatment: 3 to 10 percent. | None | Minor side effects: 50 percent. Side effects bad enough to stop treatment: 3 to 10 percent. |
| Chances for medically dangerous harms (risks) | Less than 1 percent (less than 1 in 100) | None | Less than 1% (less than 1 in 100) |
| *The chances given are for the first medicine tried. The chances that a second medicine will work are also very good. | |||
| Day of the week | Medicines I took Name of medicine(s) I am taking: |
Side effects How the medicine made me feel. |
Symptoms How I feel on a scale of 0 to 5 Bad Good └------------------┘ 0 5 |
Activities Activities for tooday: Include plans and "homework" for psychotherapy. |
Appointment schedule |
| Sample: Monday May 15th | One pill at 8 a.m and one at 8 p.m. |
Dry mouth | 2-I feel better about things today. | Went to the grocery strore. Made a list of good things about my life | Dr. Smith 3:00 |
| Sunday | |||||
| Monday | |||||
| Tuesday | |||||
| Wednesday | |||||
| Thursday | |||||
| Friday | |||||
| Satureday |
National Alliance for the Mentally Ill (NAMI)
2101 Wilson Blvd, Suite 302
Arlington, VA 22201
Toll free: 800-950-6264
National Depressive and Manic Depressive Association (NDMDA)
730 N. Franklin St., Suite 501
Chicago, IL 60610
Toll free: 800-82-NDMDA
National Foundation for Depressive Illness, Inc. (NFDI)
P.O. Box 2257
New York, NY 10116-2257
Toll free: 800-248-4344
National Mental Health Associaffon (NMHA)
National Mental Health Information Center
1021 Prince Street
Alexandria, VA 23314-2971
Toll free: 800-969-6642
Depression Awarness, Recognition, and Treatment (D/ART) Program
Department GL, Room 10-85
5600 Fishers Lane
Rockville, MD 20857
Toll Free: 800-421-4211
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