What Is Depression

Depression is an umbrella term used to describe conditions that are characterized by long-term mood irregularity and/or sadness. There are several types of depressive disorders. These are:

  • Major depression (the most common form of depression)
  • Persistent depressive disorder
  • Manic depression (Bipolar disorder)
  • Psychotic depression
  • Seasonal affective disorder
  • Postpartum depression

People who suffer from all types of depressive disorders can experience persistent feelings of sadness, loss of interest, fatigue, and are at a higher risk for debilitating physical ailments such as heart disease, obesity, and stroke. Depressive disorders can change thought patterns, behavior, physical appearances, and interfere with marriages, relationships with family and friends, and performance in the workplace.

Depression affects women almost twice as often as men – 1 in 5 women will be affected by depressive disorders during their lifetime, compared to 1 in 10 men. Among the most famous depression sufferers are Angelina Jolie, Owen Wilson, Uma Thurman, and Cheryl Crow. Though such a large number of Americans are affected by depression, only few will receive treatment. Over 80% of people experiencing symptoms of clinical depression do not seek help for their condition

According to the Centers for Disease Control, an estimated one in 10 U.S. adults suffers from depression, a mental illness that can adversely affect the course and outcome of common chronic conditions, such as arthritis, asthma, cardiovascular disease, cancer, diabetes, and obesity. Depression also can result in increased work absenteeism, short-term disability, decreased productivity, and suicide. The American Association of Suicidology reports that if left untreated, depression can lead to co-morbid mental disorders such as alcohol and substance abuse, higher rates of recurrent episodes, and higher rates of suicide.

The World Health Organization (WHO) estimates that by the year 2020, depression will be the number two cause of “lost years of healthy life” worldwide. The most recent data compiled by the Centers for Disease Control, from 1988–1994 through 2005–2008, shows that the rate of antidepressant use in the United States among all ages increased nearly 400%. About one in 10 Americans aged 12 and over takes antidepressant medication. Antidepressants were the most frequently used prescription drugs by persons aged 18 to 44 years and the third most common prescription drug taken by Americans of all ages in 2005–2008.

In addition, the CDC reports that only about one-third of people with severe depressive symptoms take antidepressant medication. The U.S. Preventive Services Task Force recommends that health-care providers screen adults for depression when programs are in place to ensure that accurate diagnosis and effective treatment can be provided with careful monitoring and follow-up. The Task Force on Community Preventive Services recommends collaborative care, an approach that involves the collaboration of primary care providers, mental health specialists and other providers to improve disease management for adults with major depression on the basis of strong evidence of effectiveness in improving short-term depression outcomes.

What Causes Depression

Depression is a complex disease with multiple causes that are still being investigated by researchers. Currently, it is believed that depression is caused by a combination of factors.

These include:

  • Hormones.  Estrogen, progesterone, and cortisol have all been identified as hormone factors of depression. 
  • Estrogen. helps raise serotonin levels, which fights against depression and allows for more regular sleep For this reason, women are at an increased risk of depression during peri-menopause and menopause, when they experience a severe drop in estrogen levels.
  • Progesterone also has anti-depressant qualities, and is present in higher qualities in pregnant women. A sharp drop in progesterone levels after giving birth is a main factor in postpartum depression.
  • Cortisol is a stress-associated hormone. High or low levels of cortisol can cause mood changes, inability to cope with stress, increased belly fat, and fatigue.
  • Brain abnormalities. Brain-imaging technologies like MRIs and PETs have shown abnormalities in the prefrontal cortex of those with depression, the area of the brain that regulates emotion, thought, decision-making, and behavior. Irregularities have also been found in the areas of the brain that control appetite and sleep.
  • Psychological factors.  This can be a traumatic experience such as the loss of a loved one or an on-going stressor such as unemployment. Those who are ruminators, worriers, negative and/or have low self-esteem are more at risk.
  • Drug and Alcohol Use.  Substance abuse can either be a cause or effect of depression. Those who abuse alcohol are at exceptional risk of depression because it is a central nervous system depressant.
  • Genetics. Vulnerability to depressive disorders can be inherited through genetic material. Support for this comes from studies that have found a strong correlation between depression in children and parents (children are at twice the risk for depression if one parent suffered from depression) and those that have found a strong correlation between depression rates in twins (There is a 76% chance that a twin will develop depression if the other twin has already experienced depression)


Risk Factors For Depression

There are many factors that can put you at an increased risk for developing depression. These are:

  • Chronic Sleep Disorders. Insomnia has been long been cited as a risk factor for depression.A study done at the University of North Texas in Denton and published in the journal Sleep in 2005 found that people with insomnia had greater depression levels than people who didn’t haveinsomnia.The participants with sleep problemswere almost 10 times morelikely to have clinically significant depression.Increased insomnia frequency was related to increased depression, and increased number of awakenings was also related to increased depression.  
  • Medications.  Sedatives and pain medications including Valium and Percocet can cause depressive symptoms.  High blood pressure meds have also been known to contribute to depression.
  • Lack of social support.  People do need people. Not having family and friends in your life can contribute to depression. A study done at Johns Hopkins and published in The Journal of Affective Disorders in 2010 found that a lack of social support — including feeling unappreciated, unloved, and uninvolved with family and friends — is one of the most potent predictors of continuing suicidal ideation, even when there are no other risk factors.
  • Quitting smoking.  Quitting smoking comes with a 25% risk of depression for at least six months in those who are prone to bouts of sadness.  So, if you quit, keep an eye out for depressive symptoms.
  • Chronic Pain Conditions.  These include fibromyalgia, arthritis, and migraines. Based on testimony given in 2005 to the United States House of Representatives by the National Institutes of Health, NIH reports that scientists don’t yet know how depression and chronic pain are linked, but states the illnesses are known to occur together. The testimony confirmed that chronic pain can worsen depression symptoms and that it is a risk factor for suicide in people who are depressed. A study done at Stanford University in 2003 found that 43 percent of the participants with major depression also had chronic pain. The researchers noted that question is which comes first: the depression or the pain. They posit that the perception of pain is greater in depressed people and pointed out that many people with depression reported more headache, back pain or limb pain rather than pain stemming from disease.
  • Hormones. Women may be at increased risk for depression during perimenopause and menopause, as this is a time of much hormonal fluctuation.

Diagnosing Depression

Your doctor will ask about your symptoms and medical history. A physical exam will be done. Your doctor may also do a mental health evaluation and search for physical causes of depression. These findings will be used to make the diagnosis. There is no blood test or specific diagnostic test for depression.

Depression is often diagnosed based on the following:

Initial assessment

Your doctor will ask about your symptoms:

  • When the symptom started
  • Any triggering events
  • How severe the symptoms are
  • How symptoms affect your daily activities
  • Their association with chronic pain
  • Whether you have had these symptoms before and, if so, whether the symptoms were treated and what treatment was given

Physical exam

Your doctor will give you a thorough physical exam. Certain medications, as well as some medical conditions, such as viral infection, can cause the same symptoms as depression. Your doctor can rule out these possibilities through a physical exam, interview, and lab tests. The physical exam may include a mental status exam to determine if your speech, thought patterns, or memory have been affected. This may indicate a neurologic cause of depression.

Psychological evaluation

A psychiatrist, psychologist, social worker, or mental health counselor can give you a psychological exam. You may take a special screening test for depression, such as the Beck Depression Inventory or the Hamilton Rating Scale. These tests have limitations, however, and must be interpreted in the context of your symptoms and personal situation.

Evaluation for other conditions that may coexist with depression, such as alcohol abuse and alcoholism, drug abuse and drug addiction,  anxiety, and personality disorders, will be done as well.

Symptoms of Depression

Not everyone who suffers from depression will experience each symptom outlined below, however if you are experiencing 5 or more of these symptoms on a daily basis, you may be depressed.

  • Feeling helpless or hopeless
  • Loss of interest in daily activities
  • Changes in weight or appetite
  • Sleep changes, either insomnia or oversleeping (known as hypersomnia)
  • Self-loathing
  • Difficulty focusing or concentrating
  • Anger or feeling irritable
  • Reckless behavior (i.e.: gambling, substance abuse)
  • Increase in physical aches and pains


Depression is a chronic illness. 50% of people who suffer from one episode of depression will suffer from another at some point during their lives, 70% of people who experience two episodes will experience a third, and 90% of those who experience three will experience a fourth. However with effective treatment, the relapse rate for depressive episodes can be much lower. The length of depressive episodes varies from person to person, and can span anywhere from a few weeks to a few years. Medications can be helpful to decrease symptoms as they appear with episodes, and therapies may be useful to help the patient identify personal patterns and warning signs of a depressive episode. The majority of patients (70-80%) report an improvement in symptoms after seeking treatment. However, only 80% of the total people affected will seek treatment in the first place.

Living With Depression

In addition to the psychotherapy and medication treatments detailed below, there are strategies you can employ to improve your results and keep depression from recurring:

Take care of yourself. This includes:

Eating well. A study published in Archives of General Psychiatry in 2009 showed a link between consuming a Mediterranean diet and a reduced risk of depression. The diet consists mainly of vegetables, fruits, nuts, whole grains, fish, and olive oil. The research, done at University of Las Palmas de Gran Canaria and Clinic of the University in Spain, found that participants who followed the Mediterranean diet most closely had a greater than 30 percent reduction in the risk of depression compared to those who had the lowest Mediterranean diet scores. The association did not change when the results were adjusted for other markers of a healthy lifestyle.

Exercising. Exercise was shown to be an effective treatment for major depressive disorder according to a report in the May 2013 issue of the Journal of Psychiatric Practice.  The authors of the article, based on research done at  Texas Southwestern Medical Center in Dallas, report that aerobic exercise is the preferred form of exercise for patients with depression but that there is also support for resistance training. They recommend that patients participate in three to five exercise sessions per week, for 45 to 60 minutes per session. In terms of intensity, for aerobic exercise, they recommend achieving a heart rate that is 50 to 85 percent of the individual’s maximum heart rate (HRmax). For resistance training, they recommend a variety of upper and lower body exercises―three sets of eight repetitions at 80 percent of 1-repetition maximum (RM—that is, 80 percent of the maximum weight that the person can lift one time). Data suggest that patients may experience improvement in depressive symptoms as little as four weeks after starting exercise.

Getting enough sleep. A genetic study of 1,788 adult twins reported links between sleep duration and depression. The studies were published in the February 1st 2014 issue of Sleep, the journal of the American Academy of Sleep Medicine. Depressive symptoms increased to 53 percent among twins with a short sleep duration of five hours per night and 49 percent among those who reported sleeping 10 hours per night. A release from the academy quotes principal investigator Dr. Nathaniel Watson, of the University of Washington Medicine Sleep Center in Seattle as saying, ” “Both short and excessively long sleep durations appear to activate genes related to depressive symptoms.” According to Watson, the study suggests that optimizing sleep may be one way to maximize the effectiveness of treatments for depression such as psychotherapy.

Taking time to laugh and have fun. Research presented at the121st Annual Meeting of the American Physiological Society in 2008 in San Diego verified earlier work showing that  the anticipation of “mirthful laughter” increased the level of beta-endorphins, the family of chemicals that alleviates depression, by 27 percent. There was no such increase among the control group who did not anticipate watching the humor film. Using a similar protocol, the 2008 research found that the same anticipation of laughter also reduced the levels of three stress hormones, epinephrine (also known as adrenaline), and dopac by39, 70 and 38 percent, respectively. 

Avoiding self blame. A study done in 2010 at University Pierre & Marie Curie in Paris found that a dysfunction of the medial prefrontal region of the brain may explain why depressed patients engage in self-blame and rumination. Cognitive behavior therapy can help diminish these problems. Yet on a daily basis, simply recognizing the destructive thoughts as they being to form and distracting yourself with upbeat activities such as exercising or watching Comedy Central shows can help derail the negative emotions.

Focusing on feelings of gratitude. Research done at Kent State University in 2008 showed that writing a letter of gratitude every two weeks to thank someone who had positively impacted participants’ lives resulted in a decrease in depressive symptoms. After the study was completed, 75 percent of the participants said they planned to continue to write letters of gratitude.

Having a support system. Surround yourself with people who care about you and who treat you well. As noted in the section on Prevention, both spiritual and social support are valuable in dealing with depression.


The U.S. Preventative Services Task Force asserts that screening improves the accurate identification of depression in adults.  They recommend primary care physicians ask these two questions of patients at regular checkups, or patients who they believe might be suffering from depression:

1.    “Over the past two weeks, have you felt down, depressed, or hopeless?”

2.   “Over the past two weeks, have you felt little interest or pleasure in doing things?”


There are many risk factors (like genetics) for depression that you cannot control, however there are many strategies you can use to help reduce your

Reduce stress. Here are some relaxation techniques that can help lower your cortisol level.

  • Visualization Close your eyes and take a mental vacation to a pleasant, calm destination such as an ocean shore. Engage all of your senses by imagining the sight of sun-dappled waves, the sound of gulls calling as they fly overhead, the scent of salt water, and the taste of ocean spray on your lips.
  • Deep breathing Inhale slowly through your nose, allowing the air to reach your diaphragm and belly so that your tummy expands completely. Next, let the breath out slowly through your mouth. Repeat for two to three minutes.
  • Professional massages A full body massage by a trained masseuse can relieves muscle tension and lower your overall stress level.
  • Mindfulness-based stress reduction (MBSR), rooted in Buddhist practices, was developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center. The technique combines meditation and sitting yoga. Many studies have shown that both meditation and yoga reduce stress and promote relaxation.

Be aware of warning signs, including the desire to isolate. According to the National Institute of Mental Health, these are the red flags:

  • Persistent sad, anxious, or “empty” feelings
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable, including sex
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details, and making decisions
  • Insomnia, early-morning wakefulness, or excessive sleeping
  • Overeating, or appetite loss
  • Thoughts of suicide, suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

Develop and maintain healthy habits – eat well, get exercise and a good night’s sleep.

 Have a strong support system, both spiritual and social:

  • Spiritual An article published in Depression Research and Treatment in 2012 found that religious and spiritual involvement is associated with positive emotions such as greater life satisfaction, well-being, hope, optimism, meaning, and purpose in life. The authors note that these feelings help to neutralize the negative emotions that underlie depression and suicide.
  • Social As for social support, numerous researchers have shown that being connected to others goes a long way toward lessening the symptoms of depression. One major study done at the Canadian Institute for Advanced Research and published in the Journal of Affective Disorders in March 2014 found “clear evidence that joining groups, and coming to identify with them, can alleviate depression.”

Help others. Reaching out to others who are suffering enables you to put things in perspective.

Check up on yourself. Ask yourself if you have fallen into bad habits such as ruminating, constantly putting yourself down, or if you have you been feeling sad or hopeless.

See a mental health professional if you catch yourself falling into any depressive behaviors. The earlier your doctor knows about your condition, the sooner he or she will be able to help you.


Medication And Treatment

It is commonly believed that depression is caused by a combination of biological, environmental and psychological factors. A complex disorder demands a multi-tiered treatment approach. This typically involves psychotherapy and sometimes medication . It is not recommended to just do medication. They stabilize you but don’t help you make lasting changes.


Types of “talk therapy” that ultimately enable you to understand the triggers for your depression and offers effective coping strategies include:

  • Psychoanalysis Developed by Sigmund Freud in the nineteenth century, this therapy delves into the patient’s subconscious to bring up impulses and behavior patterns. The relationship between the analyst and the patient is central to the work, which may require a number of s per week for many years.   to the surface, more than a century ago.
  • Cognitive-behavioral therapy.CBT offers techniques that help you change the negative internal dialogue in your mind. This type of therapy is usually brief, about four months or less. Each session involves a lesson plan and homework. You may be asked to keep a journal of your moods and to practive positive ways of thinking.
  • Psychodynamic therapy. This treatment helps you get at the causes of the depression. Sessions are typically scheduled once a week and the therapy is usually completed in a year. Treatments are modifications of psychoanalysis.

No matter what type of therapy you choose, remember it is a collaborative process and the more pro-active you are in your treatment, the more effective treatment will be.


Nearly every month, it feels as though promising new medications and treatments for depression are being announced. So don’t give up hope if the first treatment you try isn’t successful. Indeed, about 40 to 50 percent of people don’t respond to the

first anti-depressant they are prescribed. But if you persist (this involves working with a qualified and caring doctor), the right treatment can be found.

Most anti-depressants work by affecting the neurotransmitters associated with depression, in particular the neurotransmitters serotonin and norepinephrine. Each class of anti-depressants affects the neurotransmitters in slightly different ways.

The following medications are approved by the Federal Drug Administration (FDA):

Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:

  • Fluoxetine (Prozac)
  • Citalopram (Celexa)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Escitalopram (Lexapro)

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include

  • Venlafaxine (Effexor)
  • Duloxetine (Cymbalta)

Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs).

Complementary and Alternative Treatment

There are a number of complementary practices that can help with depression and/or anxiety.

Stress and relaxation techniques can help reduce symptoms of depression and anxiety. Here are some stress and relaxation practices, which have been shown to help relieve symptoms in research studies.

  • Meditation
  • Yoga
  • Acupuncture
  • Kava

Care Guide

Whether you have depression or you know someone who suffers from depression, stay mindful and aware of when and how depression presents itself.

Here are a few tips to avoid depression-triggering events and keep healthy:

  • Take meds as prescribed. Don’t decide on your own to skip or alter dosages.
  • Don’t skip therapy sessions. When you feel like cancelling is exactly when it’s most important to go. Clearly something important is cooking in your subconscious.
  • Sleep, eat healthfully, and exercise. Again, even though you don’t feel like it. Researchers the University of Washington Medicine Sleep Center in Seattle found that a healthy sleep pattern of about eight hours a night increases the effectiveness of treatments for depression. Also, eating a Mediterranean-style diet has been shown to reduce the risk of depression by 30%. In addition, data from a study on exercise and depression suggest that patients may experience improvement in depressive symptoms as little as four weeks after starting exercise, especially aerobic exercise but also resistance training. You need to rest your body, nourish it, and keep it moving!
  • Connect, don’t isolate. Remember that you are not alone. Talk to loved ones about your feelings, or find a support group to meet individuals that are experiencing the same things as you
  • Stay away from toxic people. Do not subject yourself to people who are negative and/or mean. Come to think of it, even when you feel better, stay away from toxic people.

When To Contact A Doctor

The earlier you seek help, the sooner you can stop suffering.  Visit a doctor if you:

  • Feel sad and helpless nearly every day, for most of the day
  • Rapidly gain or lose weight
  • Lose interest in activities you typically find pleasurable
  • Feel tired nearly every day for most of the day.
  • Notice changes in your sleep patterns

If you have thoughts about death or suicide, immediately call your doctor or call one of several suicide helpline .

Questions For Your Doctor

If you suspect you have depression, schedule a visit with your Primary Care Physician (PCP) for a complete physical to rule out other possible causes of your symptoms. Your doctor will then give you a referral to a counselor or therapist trained to deal with depression, who can help you feel better.

Questions For A Doctor

The following are a few questions you may want to ask your doctor during your visit:

General questions:

  • What could be causing my symptoms?
  • What should I do if these symptoms interfere with my happiness and ability to function in my relationships, work, or home life?
  • Can I have a physical exam to look for other causes?
  • Have you diagnosed and treated people with depression?
  • If not, can you refer me to a mental health professional who can diagnose and treat depression?

Questions about treatment:

  • What treatment options are available for depression?
  • What medications might help me and how long will they take to work?
  • What side effects should I watch for while on this medication and what should I do if I develop them?
  • Can you provide me with names of counselors or therapists who treat depression?

Questions about lifestyle changes:

  • What lifestyle changes can help me manage depression?
  • What resources are available to help me with healthy eating, exercise, social support, and/or stress management?

Questions about the future:

  • What are my chances of recovery from depression both with or without treatment?
  • What are the chances of my depression recurring and is there anything I can do to prevent it?

If you decide to try counseling, interview potential counselors and find one with whom you feel comfortable discussing your problems.

Ask the counselor such questions as:

  • What training and experience do you have in treating depression?
  • What is your basic approach to treatment?
  • How long will I need to be treated for depression?
  • How long are treatment sessions and how often will I have them?
  • What are your fees?
  • What health insurance do you accept?
  • Do you offer sliding scale fees to accompany various financial circumstances?

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