Everyone occasionally feels blue or sad. But these feelings are usually
short-lived and pass within a couple of days. When you have depression, it
interferes with daily life and causes pain for both you and those who care about
you. Depression is a common but serious illness.
Many people with a depressive illness never seek treatment. But the majority,
even those with the most severe depression, can get better with treatment.
Medications, psychotherapies, and other methods can effectively treat people
There are several forms of depressive disorders.
Major depressive disorder, or major depression, is
characterized by a combination of symptoms that interfere with a person's
ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major
depression is disabling and prevents a person from functioning normally. Some
people may experience only a single episode within their lifetime, but more
often a person may have multiple episodes.
Dysthymic disorder, or dysthymia, is characterized by
long-term (2 years or longer) symptoms that may not be severe enough to disable
a person but can prevent normal functioning or feeling well. People with
dysthymia may also experience one or more episodes of major depression during
Minor depression is characterized by having symptoms for 2
weeks or longer that do not meet full criteria for major depression. Without
treatment, people with minor depression are at high risk for developing major
Some forms of depression are slightly different, or they may develop under
unique circumstances. However, not everyone agrees on how to characterize and
define these forms of depression. They include:
Bipolar disorder, also called
manic-depressive illness, is not as common as major depression or dysthymia.
Bipolar disorder is characterized by cycling mood changes—from extreme highs
(e.g., mania) to extreme lows (e.g., depression).
Most likely, depression is caused by a combination of genetic, biological,
environmental, and psychological factors.
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 involved in mood, thinking, sleep, appetite, and behavior
appear different. But these images do not reveal why the depression has
occurred. They also cannot be used to diagnose depression.
Some types of depression tend to run in families. However, depression can
occur in people without family histories of depression too. Scientists are
studying certain genes that may make some people more prone to depression. Some
genetics research indicates that risk for depression results from the influence
of several genes acting together with environmental or other factors. In
addition, trauma, loss of a loved one, a difficult relationship, or any
stressful situation may trigger a depressive episode. Other depressive episodes
may occur with or without an obvious trigger.
Signs & Symptoms
"It was really hard to get out of bed in the morning. I just
wanted to hide under the covers and not talk to anyone. I didn't feel much like
eating and I lost a lot of weight. Nothing seemed fun anymore. I was tired all
the time, and I wasn't sleeping well at night. But I knew I had to keep going
because I've got kids and a job. It just felt so impossible, like nothing was
going to change or get better."
People with depressive illnesses do not all experience the same symptoms. The
severity, frequency, and duration of symptoms vary depending on the individual
and his or her particular illness.
Signs and symptoms include:
Who Is At Risk?
Major depressive disorder is one of the most common mental disorders in the
United States. Each year about 6.7% of U.S adults experience major depressive
disorder. Women are 70 % more likely than men to experience depression during
their lifetime. Non-Hispanic blacks are 40% less likely than non-Hispanic
whites to experience depression during their lifetime. The average age of onset
is 32 years old. Additionally, 3.3% of 13 to 18 year olds have experienced a
seriously debilitating depressive disorder.
"I started missing days from work, and a friend noticed that
something wasn't right. She talked to me about the time she had been really
depressed and had gotten help from her doctor."
Depression, even the most severe cases, can be effectively treated. The
earlier that treatment can begin, the more effective it is.
The first step to getting appropriate treatment is to visit a doctor or
mental health specialist. 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 doing a physical exam, interview, and
lab tests. If the doctor can find no medical condition that may be causing the
depression, the next step is a psychological evaluation.
The doctor may refer you to a mental health professional, who should discuss
with you any family history of depression or other mental disorder, and get a
complete history of your symptoms. You should discuss when your symptoms
started, how long they have lasted, how severe they are, and whether they have
occurred before and if so, how they were treated. The mental health professional
may also ask if you are using alcohol or drugs, and if you are thinking about
death or suicide.
Other illnesses may come on before depression, cause it, or be a consequence
of it. But depression and other illnesses interact differently in different
people. In any case, co-occurring illnesses need to be diagnosed and
Anxiety disorders, such as post-traumatic stress disorder (PTSD),
obsessive-compulsive disorder, panic disorder, social phobia, and generalized
anxiety disorder, often accompany depression. PTSD can occur after a person
experiences a terrifying event or ordeal, such as a violent assault, a natural
disaster, an accident, terrorism or military combat. People experiencing PTSD
are especially prone to having co-existing depression.
Alcohol and other substance abuse or dependence may also co-exist with
depression. Research shows that mood disorders and substance abuse commonly
Depression also may occur with other serious medical illnesses such as heart
disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson's disease. People who
have depression along with another medical illness tend to have more severe
symptoms of both depression and the medical illness, more difficulty adapting to
their medical condition, and more medical costs than those who do not have
co-existing depression. Treating the depression can also help improve the
outcome of treating the co-occurring illness.
Once diagnosed, a person with depression can be treated in several ways. The
most common treatments are medication and psychotherapy.
Antidepressants primarily work on brain chemicals called
neurotransmitters, especially serotonin and norepinephrine. Other
antidepressants work on the neurotransmitter dopamine. Scientists have found
that these particular chemicals are involved in regulating mood, but they are
unsure of the exact ways that they work. The latest information on medications
for treating depression is available on the U.S. Food and Drug Administration (FDA)
Popular newer antidepressants
Some of the newest and most popular antidepressants are called selective
serotonin reuptake inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloft),
escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of
the most commonly prescribed SSRIs for depression. Most are available in generic
versions. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar
to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta).
SSRIs and SNRIs tend to have fewer side effects than older antidepressants,
but they sometimes produce headaches, nausea, jitters, or insomnia when people
first start to take them. These symptoms tend to fade with time. Some people
also experience sexual problems with SSRIs or SNRIs, which may be helped by
adjusting the dosage or switching to another medication.
One popular antidepressant that works on dopamine is bupropion (Wellbutrin).
Bupropion tends to have similar side effects as SSRIs and SNRIs, but it is less
likely to cause sexual side effects. However, it can increase a person's risk
Tricyclics are older antidepressants. Tricyclics are powerful, but they are
not used as much today because their potential side effects are more serious.
They may affect the heart in people with heart conditions. They sometimes cause
dizziness, especially in older adults. They also may cause drowsiness, dry
mouth, and weight gain. These side effects can usually be corrected by changing
the dosage or switching to another medication. However, tricyclics may be
especially dangerous if taken in overdose. Tricyclics include imipramine and
Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant
medications. They can be especially effective in cases of "atypical" depression,
such as when a person experiences increased appetite and the need for more sleep
rather than decreased appetite and sleep. They also may help with anxious
feelings or panic and other specific symptoms.
However, people who take MAOIs must avoid certain foods and beverages
(including cheese and red wine) that contain a substance called tyramine.
Certain medications, including some types of birth control pills, prescription
pain relievers, cold and allergy medications, and herbal supplements, also
should be avoided while taking an MAOI. These substances can interact with MAOIs
to cause dangerous increases in blood pressure. The development of a new MAOI
skin patch may help reduce these risks. If you are taking an MAOI, your doctor
should give you a complete list of foods, medicines, and substances to
MAOIs can also react with SSRIs to produce a serious condition called
"serotonin syndrome," which can cause confusion, hallucinations, increased
sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm,
and other potentially life-threatening conditions. MAOIs should not be taken
How should I take medication?
All antidepressants must be taken for at least 4 to 6 weeks before they have
a full effect. You should continue to take the medication, even if you are
feeling better, to prevent the depression from returning.
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, suddenly ending an
antidepressant can cause withdrawal symptoms or lead to a relapse of the
depression. 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, you should consider trying
another. NIMH-funded research has shown that people who did not get well after
taking a first medication increased their chances of beating the depression
after they switched to a different medication or added another medication to
their existing one.
Sometimes stimulants, anti-anxiety medications, or other medications are used
together with an antidepressant, especially if a person has a co-existing
illness. However, neither anti-anxiety medications nor stimulants are effective
against depression when taken alone, and both should be taken only under a
doctor's close supervision.
Report any unusual side effects to a doctor immediately.
FDA warning on antidepressants
Despite the relative safety and popularity of SSRIs and other
antidepressants, 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 percent of those
taking antidepressants thought about or attempted suicide (although no suicides
occurred), compared to 2 percent 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 doctor. The latest information from the FDA can be found on their
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
What about St. John's wort?
The extract from the herb St. John's wort (Hypericum perforatum) has been
used for centuries in many folk and herbal remedies. Today in Europe, it is used
extensively to treat mild to moderate depression. However, recent studies have
found that St. John’s wort is no more effective than placebo in treating major
or minor depression.
In 2000, the FDA issued a Public Health Advisory letter stating that the herb
may interfere with certain medications used to treat heart disease, depression,
seizures, certain cancers, and those used to prevent organ transplant rejection.
The herb also may interfere with the effectiveness of oral contraceptives.
Consult with your doctor before taking any herbal supplement.
Now I'm seeing the specialist on a regular basis for "talk
therapy," which helps me learn ways to deal with this illness in my everyday
life, and I'm taking medicine for depression.
Several types of psychotherapy—or "talk therapy"—can help people with
Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and
interpersonal therapy (IPT)—are effective in treating depression. CBT helps
people with depression restructure negative thought patterns. Doing so helps
people interpret their environment and interactions with others in a positive
and realistic way. It may also help you recognize things that may be
contributing to the depression and help you change behaviors that may be making
the depression worse. IPT helps people understand and work through troubled
relationships that may cause their depression or make it worse.
For mild to moderate depression, psychotherapy may be the best option.
However, for severe depression or for certain people, psychotherapy may not be
enough. For example, for teens, a combination of medication and psychotherapy
may be the most effective approach to treating major depression and reducing the
chances of it coming back. Another study looking at depression treatment among
older adults found that people who responded to initial treatment of medication
and IPT were less likely to have recurring depression if they continued their
combination treatment for at least 2 years.
More information on psychotherapy is available on the NIMH website.
Electroconvulsive therapy and other brain stimulation
For cases in which medication and/or psychotherapy does not help relieve a
person's treatment-resistant depression, electroconvulsive therapy (ECT) may be
useful. ECT, formerly 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
Before ECT begins, a patient is put under brief anesthesia and given a muscle
relaxant. He or she sleeps through the treatment and does not consciously feel
the electrical impulses. Within 1 hour after the treatment session, which takes
only a few minutes, the patient is awake and alert.
A person typically will undergo ECT several times a week, and often will need
to take an antidepressant or other medication along with the ECT treatments.
Although some people 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. Ongoing NIMH-supported ECT research is aimed at developing
personalized maintenance ECT schedules.
ECT may cause some side effects, including confusion, disorientation, and
memory loss. Usually these side effects are short-term, but sometimes they can
linger. Newer methods of administering the treatment have reduced the memory
loss and other cognitive difficulties associated with ECT. Research has found
that after 1 year of ECT treatments, most patients showed no adverse cognitive
Other more recently introduced types of brain stimulation therapies used to
treat severe depression include vagus nerve stimulation (VNS), and repetitive
transcranial magnetic stimulation (rTMS). These methods are not yet commonly
used, but research has suggested that they show promise.
More information on ECT, VNS, rTMS and other brain stimulation therapies is
available on the NIMH website.