What are the different forms of depression? There are several forms of depressive disorders. The most
common are major depressive disorder and dysthymic
disorder.
Major depressive disorder, also called major depression,
Bipolar disorder, also
is characterized by a combination of symptoms that inter
called manic-depressive
fere with a person's ability to work, sleep, study, eat, and
illness, is not as common
enjoy once-pleasurable activities. Major depression is dis
as major depression
abling and prevents a person from functioning normally.
or dysthymia. Bipolar
An episode of major depression may occur only once in
disorder is character
a person's lifetime, but more often, it recurs throughout a
ized by cycling mood
changes—from extreme highs (e.g., mania) to
Dysthymic disorder, also called dysthymia, is character
extreme lows (e.g.,
ized by long-term (two years or longer) but less severe
depression). More in
symptoms that may not disable a person but can prevent
formation about bipolar
one from functioning normal y or feeling wel . People with
disorder is available at
dysthymia may also experience one or more episodes of
http://www.nimh.nih.
major depression during their lifetimes.
gov/healthinformation/
Some forms of depressive disorder exhibit slightly differ
bipolarmenu.cfm.
ent characteristics than those described above, or they may
develop under unique circumstances. However, not all sci
entists agree on how to characterize and define these forms
of depression. They include:
Psychotic depression, which occurs when a severe depres
sive il ness is accompanied by some form of psychosis, such
as a break with reality, hal ucinations, and delusions.
Postpartum depression, which is diagnosed if a new mother
develops a major depressive episode within one month after
delivery. It is estimated that 10 to 15 percent of women expe
rience postpartum depression after giving birth.1
Seasonal affective disorder (SAD), which is character
ized by the onset of a depressive illness during the winter
months, when there is less natural sunlight. The depression
general y lifts during spring and summer. SAD may be effec
tively treated with light therapy, but nearly half of those with
SAD do not respond to light therapy alone. Antidepressant
medication and psychotherapy can reduce SAD symptoms,
either alone or in combination with light therapy.2
What are the symptoms of depression?
People with depressive il nesses do not all experience the same symptoms.The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness.
symptoms
Persistent sad, anxious or "empty" feelings
Feelings of hopelessness and/or pessimism
Feelings of guilt, worthlessness and/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
Persistent aches or pains, headaches, cramps
or digestive problems that do not ease even
with treatment
National Institute of Mental Health
What illnesses often co-exist with depression?
Depression often co-exists with other illnesses. Such ill
nesses may precede the depression, cause it, and/or be a
consequence of it. It is likely that the mechanics behind
the intersection of depression and other il nesses differ
for every person and situation. Regardless, these other co
occurring illnesses need to be diagnosed and treated.
Anxiety disorders, such as post-traumatic stress disorder
(PTSD), obsessive-compulsive disorder, panic disorder,
social phobia and generalized anxiety disorder, often
accompany depression.3,4 People experiencing PTSD are
especial y prone to having co-occurring depression. PTSD is
a debilitating condition that can result after a person experi
ences a terrifying event or ordeal, such as a violent assault, a
natural disaster, an accident, terrorism or military combat. People with PTSD often re-live the traumatic event in flash
backs, memories or nightmares. Other symptoms include
irritability, anger outbursts, intense guilt, and avoidance of
thinking or talking about the traumatic ordeal. In a National
Institute of Mental Health (NIMH)-funded study, researchers
found that more than 40 percent of people with PTSD also
had depression at one-month and four-month intervals after
the traumatic event.5
Alcohol and other substance abuse or dependence may also
co-occur with depression. In fact, research has indicated that
the co-existence of mood disorders and substance abuse is
pervasive among the U.S. population.6
Depression also often co-exists with other serious medical
illnesses such as heart disease, stroke, cancer, hiv/AiDS,
diabetes, and Parkinson's disease. Studies have shown that
people who have depression in addition to another serious
medical illness tend to have more severe symptoms of both
depression and the medical il ness, more difficulty adapting
to their medical condition, and more medical costs than those
who do not have co-existing depression.7 Research has yielded
increasing evidence that treating the depression can also help
improve the outcome of treating the co-occurring illness.8
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 responsi
ble for regulating mood, thinking, sleep, appetite and behav
ior appear to function abnormal y. In addition, important
neurotransmitters—chemicals that brain cells use to com
municate—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.
Research indicates that depressive illnesses
are disorders of the brain.
National Institute of Mental Health
How do women experience depression? Depression is more common among women than among men.
Biological, life cycle, hormonal and psychosocial factors unique
to women may be linked to women's higher depression rate.
Researchers have shown that hormones directly affect brain chem
istry that controls emotions and mood. For example, women are
particularly vulnerable to depression after giving birth, when hor
monal and physical changes, along with the new responsibility of
caring for a newborn, can be overwhelming. Many new moth
ers experience a brief episode of the "baby blues," but some will
develop postpartum depression, a much more serious condition
that requires active treatment and emotional support for the new
mother. Some studies suggest that women who experience post
partum depression often have had prior depressive episodes. Some women may also be susceptible to a severe form of premen
strual syndrome (PMS), sometimes cal ed premenstrual dysphoric
disorder (PMDD), a condition resulting from the hormonal changes
that typically occur around ovulation and before menstruation
begins. During the transition into menopause, some women expe
rience an increased risk for depression. 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 Final y, many women face the additional stresses of work and home
responsibilities, caring for children and aging parents, abuse, pov
erty, and relationship strains. It remains unclear why some women
faced with enormous challenges develop depression, while others
with similar challenges do not. 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, worthless
ness 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, discouraged, 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 United States.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 depres
sion, 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 doctors call vascular depression,
also called arteriosclerotic depression or subcortical ischemic
depression. Vascular depression may result when blood ves
sels 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 sui
cide are among the young, older white males age 85 and older
actually have the highest suicide rate. Many have a depres
sive il ness that their doctors may not detect, despite the fact
that these suicide victims often visit their doctors 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 medica
tion 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 peri
ods free of depression, especial y for older adults with minor
depression, and it is particularly useful for those who are
unable or unwilling to take antidepressant medication.20, 21
Depression is not a normal part of aging.
National Institute of Mental Health
How do children and adolescents experience depression? Scientists and doctors have begun to take seriously the risk of
depression in children. Research has shown that childhood
depression often persists, recurs and continues into adult
hood, especially if it goes untreated. The presence of child
hood 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 nega
tive 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 emerg
ing 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 An NIMH-funded clinical trial of 439 adolescents with major
depression found that a combination of medication and psy
chotherapy was the most effective treatment option.25 Other
NIMH-funded researchers are developing and testing ways to
prevent suicide in children and adolescents, including early
diagnosis and treatment, and a better understanding of sui
Childhood depression often persists, recurs, and continues into adulthood, especially if left untreated.
How is depression detected and treated?
Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.
The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer the patient to a mental health professional.
The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should discuss any family history of depression, and get a complete history of symptoms, e.g., when they started, how long they have lasted, their severity, and whether they have occurred before and if so, how they were treated. He or she should also ask if the patient is using alcohol or drugs, and whether the patient is thinking about death or suicide.
Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.
National Institute of Mental Health
Medication
Antidepressants work to normalize naturally occurring
brain chemicals cal ed neurotransmitters, notably serotonin
and norepinephrine. Other antidepressants work on the neu
rotransmitter dopamine. Scientists studying depression have
found that these particular chemicals are involved in regu
lating mood, but they are unsure of the exact ways in which
they work.
The newest and most popular types of antidepressant
medications are called selective serotonin reuptake inhibi
tors (SSRis). SSRIs include fluoxetine (Prozac), citalopram
(Celexa), sertraline (Zoloft) and several others. Serotonin
and norepinephrine reuptake inhibitors (SNRIs) are similar
to SSRIs and include venlafaxine (Effexor) and duloxetine
(Cymbalta). SSRIs and SNRIs are more popular than the
older classes of antidepressants, such as tricyclics—named for
their chemical structure—and monoamine oxidase inhibitors
(MAOIs) because they tend to have fewer side effects. How
ever, medications affect everyone differently—no one-size
fits-all approach to medication exists. Therefore, for some
people, tricyclics or MAOIs may be the best choice. People taking MAOIs must adhere to significant food and
medicinal restrictions to avoid potential y serious interactions.
They must avoid certain foods that contain high levels of the
chemical tyramine, which is found in many cheeses, wines
and pickles, and some medications including decongestants.
MAOIs interact with tyramine in such a way that may cause a
sharp increase in blood pressure, which could lead to a stroke.
A doctor should give a patient taking an MAOI a complete list
of prohibited foods, medicines and substances.
For all classes of antidepressants, patients must take regu
lar doses for at least three to four weeks before they are
likely to experience a full therapeutic effect. They should
continue taking the medication for the time specified by their
doctor, even if they are feeling better, in order to prevent a
relapse of the depression. Medication should be stopped only
under a doctor's supervision. Some medications need to be
gradually stopped to give the body time to adjust. Although
antidepressants are not habit-forming or addictive, abruptly
ending an antidepressant can cause withdrawal symptoms
or lead to a relapse. Some individuals, such as those with
chronic or recurrent depression, may need to stay on the
medication indefinitely.
In addition, if one medication does not work, patients should
be open to trying another. NIMH-funded research has shown
that patients who did not get well after taking a first medica
tion increased their chances of becoming symptom-free after
they switched to a different medication or added another
medication to their existing one.26,27 Sometimes stimulants, anti-anxiety medications, or other
medications are used in conjunction with an antidepressant,
especial y if the patient has a co-existing mental or physical
disorder. However, neither anti-anxiety medications nor stim
ulants are effective against depression when taken alone, and
both should be taken only under a doctor's close supervision.
What are the side effects of antidepressants? Antidepressants may cause mild and often temporary side
effects in some people, but they are usually not long-term.
However, any unusual reactions or side effects that inter
fere with normal functioning should be reported to a
doctor immediately.
National Institute of Mental Health
sIde effects
The most common side effects associated with
SSRIs and SNRIs include:
Headache—usually temporary and will subside.
Nausea—temporary and usually short-lived.
Insomnia and nervousness (trouble fal ing asleep
or waking often during the night)—may occur during
the first few weeks but often subside over time or if
the dose is reduced.
Agitation (feeling jittery).
Sexual problems—both men and women can experi
ence sexual problems including reduced sex drive,
erectile dysfunction, delayed ejaculation, or inability to
Report any
have an orgasm.
unusual side
Tricyclic antidepressants also can cause side effects
effects to
including:
Dry mouth—it is helpful to drink plenty of water,
immediately.
chew gum, and clean teeth daily.
Constipation—it is helpful to eat more bran cereals,
prunes, fruits, and vegetables.
Bladder problems—emptying the bladder may be
difficult, and the urine stream may not be as strong
as usual. Older men with enlarged prostate conditions
may be more affected. The doctor should be notified if
it is painful to urinate.
Sexual problems—sexual functioning may change,
and side effects are similar to those from SSRIs.
Blurred vision—often passes soon and usual y will not
require a new corrective lenses prescription.
Drowsiness during the day—usual y passes soon,
but driving or operating heavy machinery should be
avoided while drowsiness occurs. The more sedating
antidepressants are general y taken at bedtime to
help sleep and minimize daytime drowsiness.
FDA Warning on Antidepressants Despite the relative safety and popularity of SSRIs and
other antidepressants, some studies have suggested that
they may have unintentional effects on some people,
especially adolescents and young adults. In 2004, the Food
and Drug Administration (FDA) conducted a thorough
review of published and unpublished controlled clinical
trials of antidepressants that involved nearly 4,400 children
and adolescents. The review revealed that 4% of those
taking antidepressants thought about or attempted suicide
(although no suicides occurred), compared to 2% of those
receiving placebos. This information prompted the FDA, in 2005, to adopt a
"black box" warning label on all antidepressant medications
to alert the public about the potential increased risk of
suicidal thinking or attempts in children and adolescents
taking antidepressants. In 2007, the FDA proposed that
makers of all antidepressant medications extend the warning
to include young adults up through age 24. A "black box"
warning is the most serious type of warning on prescription
drug labeling. The warning emphasizes that patients of all ages taking
antidepressants should be closely monitored, especially
during the initial weeks of treatment. Possible side effects
to look for are worsening depression, suicidal thinking
or behavior, or any unusual changes in behavior such as
sleeplessness, agitation, or withdrawal from normal social
situations. The warning adds that families and caregivers
should also be told of the need for close monitoring
and report any changes to the physician. The latest
information from the FDA can be found on their Web site
Children, adolescents and
young adults taking antidepressants
should be closely monitored.
National Institute of Mental Health
Results of a comprehensive review of pediatric trials
conducted between 1988 and 2006 suggested that the
benefits of antidepressant medications likely outweigh their
risks to children and adolescents with major depression and
anxiety disorders.28 The study was funded in part by the
National Institute of Mental Health. Also, the FDA issued a warning that combining an SSRI
or SNRI antidepressant with one of the commonly-used
"triptan" medications for migraine headache could cause a
life-threatening "serotonin syndrome," marked by agitation,
hal ucinations, elevated body temperature, and rapid changes
in blood pressure. Although most dramatic in the case of the
MAOIs, newer antidepressants may also be associated with
potential y dangerous interactions with other medications.
What about St. John's wort? The extract from St. John's wort (Hypericum perforatum),
a bushy, wild-growing plant with yellow flowers, has been
used for centuries in many folk and herbal remedies. Today
in Europe, it is used extensively to treat mild to moderate
depression. In the United States, it is one of the top-selling
botanical products. To address increasing American interests in St. John's wort,
the National Institutes of Health conducted a clinical trial to
determine the effectiveness of the herb in treating adults who
have major depression. Involving 340 patients diagnosed with
major depression, the eight-week trial randomly assigned
one-third of them to a uniform dose of St. John's wort, one-
third to a commonly prescribed SSRI, and one-third to a
placebo. The trial found that St. John's wort was no more
effective than the placebo in treating major depression.29
Another study is looking at the effectiveness of St. John's wort
for treating mild or minor depression. Other research has shown that St. John's wort can interact
unfavorably with other medications, including those used
to control HIV infection. On February 10, 2000, the FDA
issued a Public Health Advisory letter stating that the herb
appears to interfere with certain medications used to treat
heart disease, depression, seizures, certain cancers, and organ
transplant rejection. The herb also may interfere with the
effectiveness of oral contraceptives. Because of these potential
interactions, patients should always consult with their doctors
before taking any herbal supplement.
Psychotherapy Several types of psychotherapy—or "talk therapy"—can help
people with depression. Some regimens are short-term (10 to 20 weeks) and other
regimens are longer-term, depending on the needs of the indi
vidual. Two main types of psychotherapies—cognitive-behav
ioral therapy (CBT) and interpersonal therapy (IPT)—have
been shown to be effective in treating depression. By teaching
new ways of thinking and behaving, CBT helps people change
negative styles of thinking and behaving that may contribute
to their depression. IPT helps people understand and work
through troubled personal relationships that may cause their
depression or make it worse. For mild to moderate depression, psychotherapy may be the
best treatment option. However, for major depression or for
certain people, psychotherapy may not be enough. Studies
have indicated that for adolescents, a combination of medica
tion and psychotherapy may be the most effective approach
to treating major depression and reducing the likelihood for
recurrence.25 Similarly, a study examining depression treat
ment among older adults found that patients who responded
to initial treatment of medication and IPT were less likely to
have recurring depression if they continued their combina
tion treatment for at least two years.21
Electroconvulsive Therapy For cases in which medication and/or psychotherapy does
not help alleviate a person's treatment-resistant depression,
electroconvulsive therapy (ECT) may be useful. ECT, for
merly known as "shock therapy," once had a bad reputation.
But in recent years, it has greatly improved and can provide
relief for people with severe depression who have not been
able to feel better with other treatments.
National Institute of Mental Health
Before ECT is administered, a patient takes a muscle relax
ant and is put under brief anesthesia. He or she does not
consciously feel the electrical impulse administered in ECT.
A patient typical y will undergo ECT several times a week,
and often wil need to take an antidepressant or mood sta
bilizing medication to supplement the ECT treatments and
prevent relapse. Although some patients will need only a
few courses of ECT, others may need maintenance ECT,
usually once a week at first, then gradually decreasing to
monthly treatments for up to one year. ECT may cause some short-term side effects, including
confusion, disorientation and memory loss. But these side
effects typically clear soon after treatment. Research has
indicated that after one year of ECT treatments, patients
showed no adverse cognitive effects.30
What efforts are underway to improve treatment? Researchers are looking for ways to better understand,
diagnose and treat depression among all groups of people.
New potential treatments are being tested that give hope to
those who live with depression that is particularly difficult
to treat, and researchers are studying the risk factors for
depression and how it affects the brain. NIMH continues to
fund cutting-edge research into this debilitating disorder. For more information on NIMH-funded research on
depression, visit http://www.nimh.nih.gov.
The National Institute of Mental Health funds cutting-edge research into this debilitating disorder.
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 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 doctor. Encourage him or her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.
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 doctor.
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.
National Institute of Mental Health
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.
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 doctor. Others who can help are listed below.
mental health resources
Mental health specialists, such as psychiatrists, psycholo
gists, social workers, or mental health counselors
Health maintenance organizations
Community mental 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 "mental health,"
"health," "social services," "hotlines," or "physicians" for
phone numbers and addresses. An emergency room
doctor also can provide temporary help and can tell you
where and how to get further help.
National Institute of Mental Health
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 doctor.
Call 911 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 hotline of the National Suicide Prevention Lifeline at 1 800-273-TALK (1 800-273-8255); TTY: 1 800 799 4TTY (4889) to talk to a trained counselor.
Make sure you or the suicidal person is not left alone.
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for more information on depression
Visit the National Library of Medicine's
En Español, http://medlineplus.gov/spanish
For information on clinical trials for depression
National Library of Medicine Clinical Trials Database
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