Understanding Depression

Reviewed by Dr Ciaran Mulholland, MRC clinical scientist, senior lecturer and honorary consultant psychiatrist

What is depression?

The word 'depression' causes much confusion. It's often used to describe when someone is feeling 'low', 'miserable', 'in a mood' or having 'got out of bed on the wrong side'. However, doctors use the word in two different ways. They can use it to describe the symptom of a 'low mood', or to refer to a specific illness, ie a 'depressive illness'. This fact sheet relates to depression, the illness.

This confusion is made all the worse because it is often difficult to tell the difference between feeling gloomy and having a depressive illness. Doctors make a diagnosis of depression after assessing the severity of the low mood, other associated symptoms and the duration of the problem. 

Depression is very common. Almost anybody can develop the illness; it's certainly NOT a sign of weakness. Depression is also treatable. You may need to see a doctor, but there are things you can do yourself or things you can do to help somebody suffering from the illness.

What you cannot do is 'pull yourself together' – no matter whether this is what you think you should be able to do or what other people tell you to do.

People who have experienced an episode of depression are at risk of developing another in the future. A small proportion may experience an episode of depression as part of a bipolar affective disorder (manic depression), which is characterised by episodes of both low and high moods.

Who gets depressed?

• Depression is very common.
• Between 5 and 10 per cent of the population are suffering from the illness to some extent at any one time.
• Over a lifetime you have a 20 per cent, or one in five, chance of having an episode of depression.
• Women are twice as likely to get depression as men.
• Bipolar affective disorder is less common than depressive illness with a life-time risk of around one to two per cent. Men and women are equally affected.

Getting depression is not a sign of weakness. There are no particular 'personality types' that are more at risk than others.

However, some risk factors have been identified. These include inherited (genetic) factors – such as having parents or grandparents, who have suffered from depression, and non-genetic factors – such as the death of a parent when you were young.

What causes depression?

• We do not fully understand the causes of depression.
• Genes or early life experiences may make some people vulnerable.
• Stressful life events, such as losing a job or a relationship ending, may trigger an episode of depression.
• Depression can be triggered by some physical illnesses, drug treatments and recreational drugs.

It's often impossible to identify a 'cause' in many people, and this can be distressing for people who want to understand the reasons why they are ill.

However depression, like any illness, can strike for no apparent reason.

It's clear that there are definite changes in the way the brain works when a person is depressed.

• Modern brain scans that can look at how 'hard' the brain is working have shown that some areas of the brain (such as at the front) are not working as well as normal.
• Depressed patients have higher than normal levels of stress hormones.
• Various chemical systems in the brain may not be working correctly, including one known as the serotonin or 5-HT system.
• Antidepressants may help to reverse these changes.

Symptoms of depression

Stress can lead to you to feeling 'down' and 'miserable'. What is different about a depressive illness is that these feelings last for weeks or months, rather than days.

In addition to feeling low most or all of the time, many other symptoms can occur in depressive illness (though not everybody has every one).

• Being unable to gain pleasure from activities that normally would be pleasurable.
• Losing interest in normal activities, hobbies and everyday life.
• Feeling tired all of the time and having no energy.
• Difficulty sleeping or waking early in the morning (though some feel that they can't get out of bed and 'face the world').
• Having a poor appetite, no interest in food and losing weight (though some people overeat and put on weight – 'comfort eating').
• Losing interest in sex.
• Finding it difficult to concentrate and think straight.
• Feeling restless, tense and anxious.
• Being irritable.
• Losing self-confidence.
• Avoiding other people.
• Finding it harder than usual to make decisions.
• Feeling useless and inadequate – 'a waste of space'.
• Feeling guilty about who you are and what you have done.
• Feeling hopeless – that nothing will make things better.
• Thinking about suicide – this is very common. If you feel this way, talk to somebody about it. If you think somebody else might be thinking this way, ask them about it – it will not make them more likely to commit suicide.

How is depression diagnosed?

Unfortunately, there's no brain scan or blood test that can be used to diagnose when a person has a depressive illness.

The diagnosis can only be made from the symptoms.

Generally speaking a diagnosis of depression will be made if a person has a persistently low mood that significantly influences their everyday life and has been present for two weeks or more, and there are also three or four or more other symptoms of depression.

Who treats people with depression?

• General practitioners (GPs), most commonly help treat people with depression.
• Patients may also be seen by counsellors, who are often attached to GP surgeries.
• If the diagnosis is unclear, or the person is particularly ill, the GP may refer the patient to a psychiatrist.
• Patients may be referred to community psychiatric nurses (CPNs) by their GP or psychiatrist.
• People suffering from depression may also be seen by CBT therapists and other psychotherapists.

Treatments for depression

Sometimes when we are going through a 'bad patch' in our life, it's enough to talk through our problems with a friend or relative.

However, this may not be enough and we may need to seek professional help.

The important thing to remember about depression is that it's treatable.

There are many different types of treatment. These include medication and talking therapies (psychotherapy).

Psychotherapy

• There are many different forms of psychotherapy.
• Simply talking to somebody or your doctor about your problems is a form of psychotherapy and can help greatly.
• It's far better to talk about your problems than 'bottling-up' your emotions.
• More formal psychotherapy includes counselling, cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT) and dynamic psychotherapy or psychoanalysis.

As a general, rule psychotherapies are as effective as medication for the treatment of mild depression. However, for more severe illnesses, medication is likely to be needed but may be supplemented with psychotherapy.

Exactly which type of therapy a doctor recommends depends on the particular problems a patient is suffering from, the views of the patient and local availability of psychotherapy. There's little evidence to suggest that one form of therapy is better than another.

Medication

• Antidepressant medication (for example fluoxetine) helps to correct the 'low' mood and other symptoms experienced during depression – they are NOT 'happy pills'.
• Antidepressants do not change your personality.
• Antidepressants are NOT addictive.

In the last few years, there has been an explosion of new antidepressant medications. The main advantage of these new drugs is that they have fewer side effects than older drugs and so are more pleasant to take.

Your doctor will choose which medication to prescribe for you based on the side-effects of the drugs and your particular symptoms. We do not fully understand how antidepressants work. However, they appear to act on chemicals in the brain to correct the abnormalities that cause the illness.

When taking medication, it's important to remember:

• to take your medication regularly
• you are unlikely to see any improvement in your symptoms for two to four weeks after starting the medication
• once you have started to respond, you should slowly improve over several weeks
• current World Health Organization guidelines recommend that patients continue to take their medication for six months after having recovered. This is to prevent a recurrence of the illness when the medication is stopped
• antidepressants are effective for both treating episodes of depression and also for preventing further episodes of illness. Some patients who have had severe or many episodes of illness are therefore recommended to take medication for a long time
• stopping to take medication once you feel well is a common cause of a return of the symptoms of depression. You should therefore only stop after discussion with your doctor
• generally coming off antidepressants is not a problem, though usually you should gradually reduce the dose of the medication over a few weeks rather than stopping abruptly. If you stop antidepressants abruptly you may notice anxiety, headaches, stomach upset, sleep disturbance or other symptoms.

What happens if you do not respond to treatment?

Some people unfortunately do not get better with simple straightforward treatments.

It may be that they need to try a higher dose or different antidepressants. A combination of medication and psychotherapy could also be helpful.

It may be necessary for these people to be referred to a psychiatrist for more specialised help. The psychiatrist will want to talk about the problems the person is suffering and find out about background information, such as work and family, previous health or emotional problems and current medication.

The psychiatrist may then recommend different treatments. Rarely, it may be necessary for the person to be admitted to hospital if the depression is very severe. This is only necessary in about 1 in 100 patients with depression.

Electroconvulsive therapy (ECT)

Most people do not like the idea of electroconvulsive therapy (ECT). It's a treatment that is reserved only for patients who have severe depression, for which it's highly effective and can work faster than medication.

It involves having a brief anaesthetic, which sends the person to sleep for 5 to 10 minutes. While asleep, a muscle-relaxing drug is given and a small electric current is passed through the brain for a fraction of a second.

Once the person has woken, it takes half an hour or so to get over the effects of the anaesthetic.

ECT is only given under the close supervision of an anaesthetist, a psychiatrist and nursing staff.

Most commonly, ECT is administered twice a week and around 6 to 10 treatments are necessary to treat the depression, though an effect may be seen after the first one or two treatments.

There's no evidence that properly administered ECT damages the brain in any way.

What to do if you are depressed

• Talk to people about how you feel. Don't bottle things up. It is NOT a sign of weakness to get help for your problems, in the same way that it would not be to get medical help for a broken leg or a chest infection.
• Although you may not be able to do the things you normally would (such as work), try to keep active as much as you can. Lying in bed or sitting thinking about your problems can make them seem worse. Physical exercise can also help depression and keep your mind off your worries.
• Do not increase your alcohol intake to try and 'drown your sorrows' or help you sleep better. Alcohol will only make the depression worse and harder to treat.
• If you are having problems sleeping, try not to lie in bed thinking about your problems and anxieties. Do something to take your mind off your worries, such as reading or listening to the radio.
• Self-help books may be helpful. Check out the health section of any good bookshop.
• If you are feeling suicidal or desperate contact a voluntary sector organisation, such as the Samaritans.
• Always remember that you are suffering from an illness. It is not you being weak, and you can NOT simply 'pull yourself together'. Your illness is treatable. You are also NOT ALONE. Depression is extremely common.

What to do if you know somebody who is depressed

Sometimes people are not aware that they are depressed. This can happen when the depression comes on slowly.

In addition many people suffering from depression blame themselves for not coping as they normally would, rather than thinking there might be some illness that has caused them to be this way. The illness can make a person think that it would be a sign of weakness to seek help for their difficulties. If you think that this has happened to somebody, you should try to talk to him or her about it.

Also try to remember the following.

• Listening can really help.
• Avoid saying, 'pull yourself together' or other remarks that make the person think that it is their fault that they are ill.
• If the person's problems do not sort themselves out in a week or so, suggest that the person seek professional help. Remind the person that this is not a sign of weakness or of being a failure.
• Don't nag the person or try to get them to do what they normally would. Remember they are suffering from an illness.
• Remind the person that they have an illness, it's not their fault and they'll get better no matter how hopeless they feel.
• Try to help them avoid resorting to alcohol, which does not help the situation. If the person talks of harming themself or committing suicide, take this seriously. Insist that they see a doctor.
• Remember that it does NOT increase the chances of a person committing suicide to talk to them about it.

Based on a text by Dr Hamish McAllister-Williams, MRC clinical scientist, senior lecturer and honorary consultant psychiatrist

http://www.netdoctor.co.uk/whoisnd.htm