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• Highlights
• Introduction
• Causes
• Risk Factors
• Complications of Depression
• Diagnosis
• Treatment
• Antidepressants and Drug Treatment Guidelines
• Psychotherapy
• Other Treatments
• Lifestyle Changes
• Resources
• References

Depression

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of depression.

Alternative Names

Seasonal affective disorder

Treatment

Depression is a treatable illness, with many therapeutic options available. Increasingly, professionals are viewing major depression as a chronic illness (the condition nearly always returns when treatment is stopped). Therefore, medical intervention and help must be ongoing.

Patients with chronic depression have a number of options, including psychotherapy, antidepressants, or both. In general, the treatment choice depends on the degree and type of depression and other accompanying conditions. It also may depend on age, pregnancy status, or other individual factors.

Unfortunately, an important 2003 study reported that even when depression is diagnosed, only about 20% of Americas with major depression receive adequate treatment. Most patients are treated by their family doctor, who may not have sufficient information or training on dosages or specific drugs that would be best suited for individual cases. Even worse, about half of people with depression, particularly the elderly, do not receive any therapy at all. Lack of health insurance is a major factor in these low treatment rates.

Patients with Major Depression. Numerous studies support a combination of cognitive behavioral therapy (CBT) plus antidepressants (typically an SSRI, such as Prozac) given for at least 60 days. CBT is used to resolve any residual symptoms after medication has been started. Some studies estimate that only 40% of people with chronic depression respond to medications alone compared to 60% who are given combination treatment.

For those who fail medications and psychotherapy, other techniques, such as electroconvulsive therapy (ECT), are safe and effective. In recent years, experimental procedures, such as vagus nerve stimulation and repetitive transcranial magnetic stimulation, have also been found to help in some cases of treatment-resistant depression. Researchers are also investigating new types of drugs (such as ketamine), which may provide a rapid, if temporary, improvement for these patients. However, according to several important 2006 studies, the more treatment strategies that patients need, the less likely they are to recover completely from depression.

Patients with Minor Depression. Patients with minor depression (fewer than five symptoms that persist for less than 2 years) may respond well to watchful waiting and supportive care. For example, one study found that newer antidepressants were only modestly helpful in older patients with mild depression. Supportive care that consists only of brief and occasional counseling sessions with the family doctor may be as helpful as antidepressants in some cases.

Patients with Depression and Other Psychiatric Problems. Other psychiatric problems often coexist with depression. If patients also suffer from anxiety, treating the depression first often relieves both problems. More severe psychiatric problems, such as bipolar disorder or schizophrenia, require specialized treatments.

Patients with Depression and Medical Conditions. Depression can worsen many medical conditions and may even increase mortality rates from some disorders, such as heart attack and stroke. Depression, then, should be aggressively treated in anyone with a serious medical problem.

Patients with Depression and Substance Abuse Problems. Treating depression in patients who abuse alcohol or drugs is important and can sometimes help patients quit.

Choosing a Therapist

Most people with depression can be treated in an office setting by a psychiatrist or other therapist. Infrequently, the level of dysfunction may be serious enough to warrant hospitalization to provide protection from further deterioration or self-harm.

Health professionals who can prescribe antidepressants include:

• Psychiatrists (mental health professionals with MD degrees)
• Doctors
• Some nurse clinicians

Although other mental health professionals cannot prescribe drugs, most therapists have arrangements with a psychiatrist for providing medications to their patients. In general, mental health professionals are categorized by their training:

• Psychoanalysts tend to have a degree in psychiatry, psychology, or social work as well as several years of training at a psychoanalytic institute.
• Psychologists have graduate-level training, including an internship in a mental healthcare facility.
• A clinical social worker has a master's degree and 2 years of supervised experience in mental health and human services.
• Advanced-practice psychiatric nurses have a master's degree and can provide therapeutic services.

Tips for Selecting a Therapist:

• Patients can locate a mental health professional in their area by asking their doctor for a referral or by contacting a mental health organization. [See Resources .]
• The patient should describe problems briefly but specifically over the phone to any prospective therapist to get a sense of whether he or she will suit the patient's needs.
• An advanced degree does not necessarily guarantee quality therapy. The patient's belief in their health care provider may be the most important component in recovery, as indicated by studies reporting that placebos relieve depression in about a third of patients and in some cases actually work better than psychotherapy.
• Patients should not be shy about considering a change in their therapist if they lack confidence in their current one.

Depression in the Elderly

Although depression in the elderly is very common, the aging process itself is unlikely to be the cause in most cases. An Italian study, for example, indicated that the very old (people who lived beyond 90 years of age) were no more likely to be depressed than younger adults. (The rate was 10% in both groups.) Studies on the cause or extent of depression in the elderly are not clear.

The severity of depression in elderly patients is strongly associated with poor health and less ability to function. In one study of older adults undergoing rehabilitation, half of whom were depressed, as their function improved so did their mood.

Anyone who experiences cumulative negative life events, physical illness, the death of a loved one, impaired functioning, or loss of independence can become deeply depressed. The elderly are at highest risk for such events, Interestingly, in this regard, one study suggested that pessimistic elderly people are less prone to depression than their optimistic peers -- possibly because pessimists are more likely expect and therefore adapt to negative experiences than those with an optimistic personality.

Diagnosing Depression in the Elderly

Because of the complex relationship between depression, drug interactions, and serious physical illness in the elderly, an accurate diagnosis in this group is important but not always straightforward. The characteristic symptoms of depression are not always present or readily apparent in older people:

• Some older people may be aware of their depression but believe that nothing can be done about it.
• Many elderly people who are depressed may report only physical symptoms (aches and pains) or other mood states (confusion, agitation, anxiety, and irritability) related to depression rather than depression itself.
• Often they are unable or unwilling to express their feelings or are even unaware that they are depressed.
• Their symptoms are often ignored or confused with other ailments common in the elderly, including Parkinson's or Alzheimer's disease, dementia, thyroid disorders, arthritis, stroke, cancer, heart disease, and other chronic conditions.
• Depression is also a side effect of many drugs that are commonly prescribed for the elderly. It is often very difficult, then, to determine if the patient's depression is a psychologic reaction to the illness, caused by the disease itself, or completely independent from the medical condition. Both physical and emotional conditions should be considered in making a diagnosis in older people.

Physical and Mental Consequences of Depression in the Elderly

Many studies suggest strong associations between even mild depression and poorer quality of life as well as a shorter lifespan.

Risk for Suicide in the Elderly . Suicide in the elderly is the third-leading cause of death related to injury. Men account for 81% of these suicides, with divorced or widowed men at highest risk.

Effects of Depression on the Ability to Function . A 2000 study indicated that even mild depressive symptoms in people aged 65 and above are associated with a higher risk of becoming disabled and having a lower chance of recovery.

Heart Disease and Heart Attacks . Depression increases the severity of a heart attack and may even impair a patient's response to medication for heart disease. Although people with heart disease may certainly become depressed, this does not explain entirely the link between the two problems. Data suggest that depression itself may be a true risk factor for heart disease as well as its increased severity.

A number of studies indicate that depression has biologic effects on the heart, including a higher risk for blood clotting, changes in heart rate, and impaired blood flow to the heart (particularly in response to mental stress). A 2001 study, for example, reported an association between depression and a greater risk for death from heart problems even in people without a history of heart disease. A 2002 study reported a higher risk for heart failure in women -- although not in men -- with depression. However, simply treating depression does not improve survival rates after a heart attack --only treating heart disease does this.

The more severe the depression, the more dangerous to the health, although even mild depression, including feelings of hopelessness, experienced over many years, may harm the heart, even in people with no early signs of heart disease.

Stroke . Depression has also been linked to a higher risk for having a stroke and lower survival rates after one. In a 2000 study, patients with severe depression had a 73% higher risk for stroke, and those with moderate depression had a 25% higher risk than average. The risk for stroke in depressed African-Americans in the study was notable, 160% higher than average. Furthermore, a 2001 study confirmed that self-reported negative mood symptoms correlated with increased mortality up to 2 years after a stroke. Some research suggests that injuries in the brain after a stroke can cause depression.

Mental Decline . Depression in the elderly is associated with a decline in mental functioning, regardless of the presence of dementia. Depression may be a predictor or even a cause of Alzheimer's disease. Brain scans in the elderly, for example, have reported greater atrophy in the brains of depressed individuals than in those of nondepressed ones.

Osteoporosis . Some studies have linked past and current major depression with bone-density loss in women. One explanation for this association is that depressed women have higher levels of the stress hormone cortisol, which may contribute to bone density loss.

Treating Depression in the Elderly

Some experts recommend only psychotherapy or attention intervention for elderly patients with mild depression. In many older patients, a regular exercise program may be sufficient to improve mood. Ideally, elderly people with more serious depression should be treated with a combination of psychotherapy and antidepressants on an ongoing basis, even after their depressive symptoms are relieved. A 2006 study of patients over age 70 indicated that the best way to prevent relapse is to continue antidepressant drug therapy for at least 2 years after the patient becomes symptom-free.

The use of antidepressants in the elderly is problematic:

• Tricyclics are as effective as, and less expensive than, SSRIs, but they have more side effects. Specifically, they pose a higher risk for adverse effects on the heart and possibly the lungs. (The older tricyclics, such as amitriptyline and imipramine, have other severe side effects in older adults.)
• SSRIs have fewer side effects than tricyclics. However, contrary to common belief, SSRIs do not appear to pose any lower risk for falls than the older tricyclic antidepressants. (The effect of the newer antidepressants on falling is not yet known.) In any case, patients with Parkinson's may want to avoid SSRIs because they can increase the risk for tremor and other symptoms of the disease.

Depression in Children and Adolescents

Depressed children often suffer in silence, and depression may be evident only from reports of problems in school. It is also often difficult for adults to believe that children can be chronically depressed. Symptoms for depression in children often differ from those in adults and may include the following:

• An inability to enjoy favorite activities
• Persistent sadness
• Increased irritability
• Complaints of physical problems, such as headaches and stomachaches
• Poor performance in school
• Persistent boredom
• Low energy
• Poor concentration
• Changes in eating and/or sleeping patterns
• A greater tendency to bully others -- anxious children are more often bullied.

Risk Factors for Depression in Children and Adolescents

Depression can occur in children of all ages, including preschoolers, although adolescents have the highest risk (about 20%). Risk factors for depression in young people include having parents, particularly mothers with depression. Early negative experiences and exposure to stress also pose a risk for depression. Sometimes depression develops after a physical illness. In adolescents, feeling alienated from parents is a strong predictor for depression.

Consequences of Depression in Children and Adolescents

Outlook for Future Emotional Problems. Adolescents who have depression are at significantly higher risk for substance abuse, recurring depression, and other emotional problems (such as bipolar disorder) in adulthood.

Risk for Suicide in Adolescents. Suicide is the third most common cause of death among adolescents, and is one of the most devastating events than can happen to a family. Suicide is most commonly associated with depression in young people but it is also linked with anxiety, psychosis, substance abuse, or impulsivity. More girls attempt suicide but more boys succeed, most often because they choose guns or violent methods while girls tend to overdose, which is more treatable. Nevertheless, attempts are major risk factors for a later suicide. Any expression of suicidal intent should be treated very seriously.

The following are danger signs in young people:

• Withdrawal from friends
• Sudden decrease in school performance
• Loss of interest in activities that were previously pleasurable
• Unusual irritability
• Unusual changes in sleep or eating habits

Risk factors for suicide include a history of neglect or abuse, history of deliberate self-harm, a family member who committed suicide (nearly always one who shared a common mood disorder), access to firearms, and living in communities where there have been recent outbreaks of suicide in young people. A romantic break-up is often the trigger for a suicidal attempt in teenagers. Feeling connected with parents and family protected young people with depression in one study, regardless of gender or ethnicity.

In one study, adolescents failed to seek help for suicidal thoughts for the following reasons:

• They believed nothing would help
• They were reluctant to tell anyone they had problems
• They thought it was a sign of weakness to seek help
• They did not know where to go

Parents should not hesitate to seek professional help for their children if they suspect they are thinking about killing themselves. This is a medical emergency and requires immediate treatment.

Behavioral therapies and antidepressants are promising treatments for preventing suicide but need study. There has been a decline in adolescent suicides over the past decade, which some experts attributed to the increased use of antidepressants in this population. However, recent evidence has indicated that antidepressants can indeed raise the risk for suicidality (suicidal thoughts and behavior). Children and adolescents who are prescribed antidepressant medication should be carefully monitored by both their parents and doctor, especially during the first few months of treatment, for any worsening of depression symptoms or changes in behavior. [See Suicide Risk and Antidepressant Medications in Treatment section.]

Treating Depression in Children and Adolescents

About 2% of American primary school-age children and 4 - 8% of adolescents suffer from depression. Studies suggest that when children or adolescents are treated, up to 80% recover. Still, 25 - 50% of these young people have a recurrence of depression within 2 years of their first episode of depression.

It is important to recognize that childhood depression differs from adult depression and that children may respond differently than adults to antidepressant medication. These variances are due to childhood brain development processes as well as age-related differences in drug metabolism. Children may experience medication side effects not seen in adults, and some antidepressants that are effective for adults may not work for children.

Mild-to-Moderate Depression. Children and adolescents with mild-to-moderate depression should receive psychotherapy before medications are tried. Cognitive therapy may be the best approach for children and adolescents with depression. (It may even be helpful in preventing depression in young people whose parents have a history of depression.) Some studies suggest that other types of psychotherapy, such as family therapy and supportive therapy, can also be very effective.

Severe Depression. The American Academy of Child and Adolescent Psychiatry recommends the SSRI antidepressants for children and adolescents with very severe depression that does not respond to psychotherapy. Tricyclic antidepressants do not tend to help adolescents and children and these drugs have many side effects. MAOIs are also not commonly prescribed.

Many SSRIs appear to be safe and effective, but at this time fluoxetine (Prozac) is the only one to be approved for children over age 7 and for adolescents. The FDA strongly advises against the use of specific SSRIs, such as paroxetine (Paxil), due to increased risk for suicidal behavior as well as the lack of any evidence supporting the drug's efficacy in pediatric patients.

For optimal results, SSRIs should be combined during the early acute phase with a mixture of psychotherapies, including cognitive-behavioral, interpersonal, and psychodynamic therapies. A 2004 study of adolescents with depression reported that combination treatment with fluoxetine and cognitive behavioral therapy was more effective than either treatment alone. Initial drug treatments should continue for at least 6 months, and a maintenance phase should last another year or longer.

The FDA is preparing a medication guide on the use of antidepressants in children and adolescents. Preliminary guidelines include the recommendation that caregivers and doctors be vigilant for any signs of suicidal intent or behavioral changes, particularly during the early phases of treatment, and that patients should see their doctor regularly after initiating drug therapy. [For more detailed information, see Suicide Risk and Antidepressant Medications .]

• Review Date: 12/21/2006
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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