TYPES OF DEPRESSION
Depressive disorders come in different forms, just as is the
case with other illnesses such as heart disease. This page briefly describes three of the most common types of depressive
disorders. However, within these types there are variations in the
number of symptoms, their severity, and persistence.
Major depression is manifested by
a combination of symptoms (see symptom list) that interfere with
the ability to work, study, sleep, eat, and enjoy once pleasurable
activities. Such a disabling episode of depression may occur only
once but more commonly occurs several times in a lifetime.
A less severe type of depression, dysthymia,
involves long-term, chronic symptoms that do not disable, but keep
one from functioning well or from feeling good. Many people with
dysthymia also experience major depressive episodes at some time
in their lives.
Another type of depression is bipolar
disorder, also called manic-depressive illness. Not
nearly as prevalent as other forms of depressive disorders,
bipolar disorder is characterized by cycling mood changes: severe
highs (mania) and lows (depression). Sometimes the mood switches
are dramatic and rapid, but most often they are gradual. When in
the depressed cycle, an individual can have any or all of the
symptoms of a depressive disorder. When in the manic cycle, the
individual may be overactive, overtalkative, and have a great deal
of energy. Mania often affects thinking, judgment, and social
behavior in ways that cause serious problems and embarrassment.
For example, the individual in a manic phase may feel elated, full
of grand schemes that might range from unwise business decisions
to romantic sprees. Mania, left untreated, may worsen to a
SYMPTOMS OF DEPRESSION AND MANIA
Not everyone who is depressed or manic experiences every
symptom. Some people experience a few symptoms, some many.
Severity of symptoms varies with individuals and also varies over
- Persistent sad, anxious, or "empty" mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies and activities that
were once enjoyed, including sex
- Decreased energy, fatigue, being "slowed down"
- Difficulty concentrating, remembering, making decisions
- Insomnia, early-morning awakening, or oversleeping
- Appetite and/or weight loss or overeating and weight gain
- Thoughts of death or suicide; suicide attempts
- Restlessness, irritability
- Persistent physical symptoms that do not respond to
treatment, such as headaches, digestive disorders, and chronic
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep
- Grandiose notions
- Increased talking
- Racing thoughts
- Increased sexual desire
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
CAUSES OF DEPRESSION
Some types of depression run in families, suggesting that a
biological vulnerability can be inherited. This seems to be the
case with bipolar disorder. Studies of families in which members
of each generation develop bipolar disorder found that those with
the illness have a somewhat different genetic makeup than those
who do not get ill. However, the reverse is not true: Not
everybody with the genetic makeup that causes vulnerability to
bipolar disorder will have the illness. Apparently additional
factors, possibly stresses at home, work, or school, are involved
in its onset.
In some families, major depression also seems to occur
generation after generation. However, it can also occur in people
who have no family history of depression. Whether inherited or
not, major depressive disorder is often associated with changes in
brain structures or brain function.
People who have low self-esteem, who consistently view
themselves and the world with pessimism or who are readily
overwhelmed by stress, are prone to depression. Whether this
represents a psychological predisposition or an early form of the
illness is not clear.
In recent years, researchers have shown that physical changes
in the body can be accompanied by mental changes as well. Medical
illnesses such as stroke, a heart attack, cancer, Parkinson's
disease, and hormonal disorders can cause depressive illness,
making the sick person apathetic and unwilling to care for his or
her physical needs, thus prolonging the recovery period. Also, a
serious loss, difficult relationship, financial problem, or any
stressful (unwelcome or even desired) change in life patterns can
trigger a depressive episode. Very often, a combination of
genetic, psychological, and environmental factors is involved in
the onset of a depressive disorder. Later episodes of illness
typically are precipitated by only mild stresses, or none at all.
Depression in Women
Women experience depression about twice as often as men. Many
hormonal factors may contribute to the increased rate of
depression in women-particularly such factors as menstrual cycle
changes, pregnancy, miscarriage, postpartum period, pre-menopause,
and menopause. Many women also face additional stresses such as
responsibilities both at work and home, single parenthood, and
caring for children and for aging parents.
A recent NIMH study showed that in the case of severe
premenstrual syndrome (PMS), women with a preexisting
vulnerability to PMS experienced relief from mood and physical
symptoms when their sex hormones were suppressed. Shortly after
the hormones were re-introduced, they again developed symptoms of
PMS. Women without a history of PMS reported no effects of the
Many women are also particularly vulnerable after the birth of
a baby. The hormonal and physical changes, as well as the added
responsibility of a new life, can be factors that lead to
postpartum depression in some women. While transient
"blues" are common in new mothers, a full-blown
depressive episode is not a normal occurrence and requires active
intervention. Treatment by a sympathetic physician and the
family's emotional support for the new mother are prime
considerations in aiding her to recover her physical and mental
well-being and her ability to care for and enjoy the infant.
Depression in Men
Although men are less likely to suffer from depression than
women, 3 to 4 million men in the United States are affected by the
illness. Men are less likely to admit to depression, and doctors
are less likely to suspect it. The rate of suicide in men is four
times that of women, though more women attempt it. In fact, after
age 70, the rate of men's suicide rises, reaching a peak after age
Depression can also affect the physical health in men
differently from women. A new study shows that, although
depression is associated with an increased risk of coronary heart
disease in both men and women, only men suffer a high death rate.
Men's depression is often masked by alcohol or drugs, or by the
socially acceptable habit of working excessively long hours.
Depression typically shows up in men not as feeling hopeless and
helpless, but as being irritable, angry, and discouraged; hence,
depression may be difficult to recognize as such in men. Even if a
man realizes that he is depressed, he may be less willing than a
woman to seek help. Encouragement and support from concerned
family members can make a difference. In the workplace, employee
assistance professionals or worksite mental health programs can be
of assistance in helping men understand and accept depression as a
real illness that needs treatment.
Depression in the Elderly
Some people have the mistaken idea that it is normal for the
elderly to feel depressed. On the contrary, most older people feel
satisfied with their lives. Sometimes, though, when depression
develops, it may be dismissed as a normal part of aging.
Depression in the elderly, undiagnosed and untreated, causes
needless suffering for the family and for the individual who could
otherwise live a fruitful life. When he or she does go to the
doctor, the symptoms described are usually physical, for the older
person is often reluctant to discuss feelings of hopelessness,
sadness, loss of interest in normally pleasurable activities, or
extremely prolonged grief after a loss.
Recognizing how depressive symptoms in older people are often
missed, many health care professionals are learning to identify
and treat the underlying depression. They recognize that some
symptoms may be side effects of medication the older person is
taking for a physical problem, or they may be caused by a
co-occurring illness. If a diagnosis of depression is made,
treatment with medication and/or psychotherapy will help the
depressed person return to a happier, more fulfilling life. Recent
research suggests that brief psychotherapy (talk therapies that
help a person in day-to-day relationships or in learning to
counter the distorted negative thinking that commonly accompanies
depression) is effective in reducing symptoms in short-term
depression in older persons who are medically ill. Psychotherapy
is also useful in older patients who cannot or will not take
medication. Efficacy studies show that late-life depression can be
treated with psychotherapy.
Improved recognition and treatment of depression in late life
will make those years more enjoyable and fulfilling for the
depressed elderly person, the family, and caretakers.
Depression in Children
Only in the past two decades has depression in children been
taken very seriously. The depressed child may pretend to be sick,
refuse to go to school, cling to a parent, or worry that the
parent may die. Older children may sulk, get into trouble at
school, be negative, grouchy, and feel misunderstood. Because
normal behaviors vary from one childhood stage to another, it can
be difficult to tell whether a child is just going through a
temporary "phase" or is suffering from depression.
Sometimes the parents become worried about how the child's
behavior has changed, or a teacher mentions that "your child
doesn't seem to be himself." In such a case, if a visit to
the child's pediatrician rules out physical symptoms, the doctor
will probably suggest that the child be evaluated, preferably by a
psychiatrist who specializes in the treatment of children. If
treatment is needed, the doctor may suggest that another
therapist, usually a social worker or a psychologist, provide
therapy while the psychiatrist will oversee medication if it is
needed. Parents should not be afraid to ask questions: What are
the therapist's qualifications? What kind of therapy will the
child have? Will the family as a whole participate in therapy?
Will my child's therapy include an antidepressant? If so, what
might the side effects be?
The National Institute of Mental Health (NIMH) has identified
the use of medications for depression in children as an important
area for research. The NIMH-supported Research Units on Pediatric
Psychopharmacology (RUPPs) form a network of seven research sites
where clinical studies on the effects of medications for mental
disorders can be conducted in children and adolescents. Among the
medications being studied are antidepressants, some of which have
been found to be effective in treating children with depression,
if properly monitored by the child's physician.
DIAGNOSTIC EVALUATION AND TREATMENT
The first step to getting appropriate treatment for depression
is a physical examination by a physician. Certain medications as
well as some medical conditions such as a viral infection can
cause the same symptoms as depression, and the physician should
rule out these possibilities through examination, interview, and
lab tests. If a physical cause for the depression is ruled out, a
psychological evaluation should be done, by the physician or by
referral to a psychiatrist or psychologist.
A good diagnostic evaluation will include a complete history of
symptoms, i.e., when they started, how long they have lasted, how
severe they are, whether the patient had them before and, if so,
whether the symptoms were treated and what treatment was given.
The doctor should ask about alcohol and drug use, and if the
patient has thoughts about death or suicide. Further, a history
should include questions about whether other family members have
had a depressive illness and, if treated, what treatments they may
have received and which were effective.
Last, a diagnostic evaluation should include a mental status
examination to determine if speech or thought patterns or memory
have been affected, as sometimes happens in the case of a
depressive or manic-depressive illness.
Treatment choice will depend on the outcome of the evaluation.
There are a variety of antidepressant medications and
psychotherapies that can be used to treat depressive disorders.
Some people with milder forms may do well with psychotherapy
alone. People with moderate to severe depression most often
benefit from antidepressants. Most do best with combined
treatment: medication to gain relatively quick symptom relief and
psychotherapy to learn more effective ways to deal with life's
problems, including depression. Depending on the patient's
diagnosis and severity of symptoms, the therapist may prescribe
medication and/or one of the several forms of psychotherapy that
have proven effective for depression.
Electroconvulsive therapy (ECT) is useful, particularly for
individuals whose depression is severe or life threatening or who
cannot take antidepressant medication. ECT often is effective in
cases where antidepressant medications do not provide sufficient
relief of symptoms. In recent years, ECT has been much improved. A
muscle relaxant is given before treatment, which is done under
brief anesthesia. Electrodes are placed at precise locations on
the head to deliver electrical impulses. The stimulation causes a
brief (about 30 seconds) seizure within the brain. The person
receiving ECT does not consciously experience the electrical
stimulus. For full therapeutic benefit, at least several sessions
of ECT, typically given at the rate of three per week, are
There are several types of antidepressant medications used to
treat depressive disorders. These include newer
medications-chiefly the selective serotonin reuptake inhibitors (SSRIs)-the
tricyclics, and the monoamine oxidase inhibitors (MAOIs). The
SSRIs-and other newer medications that affect neurotransmitters
such as dopamine or norepinephrine-generally have fewer side
effects than tricyclics. Sometimes the doctor will try a variety
of antidepressants before finding the most effective medication or
combination of medications. Sometimes the dosage must be increased
to be effective. Although some improvements may be seen in the
first few weeks, antidepressant medications must be taken
regularly for 3 to 4 weeks (in some cases, as many as 8 weeks)
before the full therapeutic effect occurs.
Patients often are tempted to stop medication too soon. They
may feel better and think they no longer need the medication. Or
they may think the medication isn't helping at all. It is
important to keep taking medication until it has a chance to work,
though side effects (see section on Side Effects on page 13) may
appear before antidepressant activity does. Once the individual is
feeling better, it is important to continue the medication for at
least 4 to 9 months to prevent a recurrence of the depression. Some
medications must be stopped gradually to give the body time to
adjust. Never stop taking an antidepressant
without consulting the doctor for instructions on how to safely
discontinue the medication. For individuals with bipolar
disorder or chronic major depression, medication may have to be
Antidepressant drugs are not habit-forming. However, as is the
case with any type of medication prescribed for more than a few
days, antidepressants have to be carefully monitored to see if the
correct dosage is being given. The doctor will check the dosage
and its effectiveness regularly.
For the small number of people for whom MAO inhibitors are the
best treatment, it is necessary to avoid certain foods that
contain high levels of tyramine, such as many cheeses, wines, and
pickles, as well as medications such as decongestants. The
interaction of tyramine with MAOIs can bring on a hypertensive
crisis, a sharp increase in blood pressure that can lead to a
stroke. The doctor should furnish a complete list of prohibited
foods that the patient should carry at all times. Other forms of
antidepressants require no food restrictions.
Medications of any kind-prescribed,
over-the counter, or borrowed-should never be
mixed without consulting the doctor. Other health
professionals who may prescribe a drug-such as a dentist or other
medical specialist-should be told of the medications the patient
is taking. Some drugs, although safe when taken alone can, if
taken with others, cause severe and dangerous side effects. Some
drugs, like alcohol or street drugs, may reduce the effectiveness
of antidepressants and should be avoided. This includes wine,
beer, and hard liquor. Some people who have not had a problem with
alcohol use may be permitted by their doctor to use a modest
amount of alcohol while taking one of the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants. They
are sometimes prescribed along with antidepressants; however, they
are not effective when taken alone for a depressive disorder.
Stimulants, such as amphetamines, are not effective
antidepressants, but they are used occasionally under close
supervision in medically ill depressed patients.
Questions about any antidepressant prescribed, or
problems that may be related to the medication, should be
discussed with the doctor.
Lithium has for many years been the treatment of choice for
bipolar disorder, as it can be effective in smoothing out the mood
swings common to this disorder. Its use must be carefully
monitored, as the range between an effective dose and a toxic one
is small. If a person has preexisting thyroid, kidney, or heart
disorders or epilepsy, lithium may not be recommended.
Fortunately, other medications have been found to be of benefit in
controlling mood swings. Among these are two mood-stabilizing
anticonvulsants, carbamazepine (Tegretol®) and
valproate (Depakote®). Both of these medications have
gained wide acceptance in clinical practice, and valproate has
been approved by the Food and Drug Administration for first-line
treatment of acute mania. Other anticonvulsants that are being
used now include lamotrigine (Lamictal®) and
gabapentin (Neurontin®): their role in the treatment
hierarchy of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one
medication including, along with lithium and/or an anticonvulsant,
a medication for accompanying agitation, anxiety, depression, or
insomnia. Finding the best possible combination of these
medications is of utmost importance to the patient and requires
close monitoring by the physician.
Antidepressants may cause mild and, usually, temporary side
effects (sometimes referred to as adverse effects) in some people.
Typically these are annoying, but not serious. However, any
unusual reactions or side effects or those that interfere with
functioning should be reported to the doctor immediately. The most
common side effects of tricyclic antidepressants, and ways to deal
with them, are:
- Dry mouth-it is helpful to drink sips of water; chew
sugarless gum; clean teeth daily.
- Constipation-bran cereals, prunes, fruit, and
vegetables should be in the diet.
- Bladder problems-emptying the bladder may be
troublesome, and the urine stream may not be as strong as
usual; the doctor should be notified if there is marked
difficulty or pain.
- Sexual problems-sexual functioning may change; if
worrisome, it should be discussed with the doctor.
- Blurred vision-this will pass soon and will not
usually necessitate new glasses.
- Dizziness-rising from the bed or chair slowly is
- Drowsiness as a daytime problem-this usually passes
soon. A person feeling drowsy or sedated should not drive or
operate heavy equipment. The more sedating antidepressants are
generally taken at bedtime to help sleep and minimize daytime
The newer antidepressants have different types of side effects:
- Headache-this will usually go away.
- Nausea-this is also temporary, but even when it
occurs, it is transient after each dose.
- Nervousness and insomnia (trouble falling asleep or
waking often during the night)-these may occur during the
first few weeks; dosage reductions or time will usually
- Agitation (feeling jittery)-if this happens for the
first time after the drug is taken and is more than transient,
the doctor should be notified.
- Sexual problems-the doctor should be consulted if the
problem is persistent or worrisome.
In the past few years, much interest has risen in the use of
herbs in the treatment of both depression and anxiety. St. John's
wort (Hypericum perforatum), an herb used extensively in
the treatment of mild to moderate depression in Europe, has
recently aroused interest in the United States. St. John's wort,
an attractive bushy, low-growing plant covered with yellow flowers
in summer, has been used for centuries in many folk and herbal
remedies. Today in Germany, Hypericum is used in the treatment of
depression more than any other antidepressant. However, the
scientific studies that have been conducted on its use have been
short-term and have used several different doses.
Because of the widespread interest in St. John's wort, the
National Institutes of Health (NIH) conducted a 3-year study,
sponsored by three NIH components-the National Institute of Mental
Health, the National Center for Complementary and Alternative
Medicine, and the Office of Dietary Supplements. The study was
designed to include 336 patients with major depression of moderate
severity, randomly assigned to an 8-week trial with one-third of
patients receiving a uniform dose of St. John's wort, another
third sertraline, a selective serotonin reuptake inhibitor (SSRI)
commonly prescribed for depression, and the final third a placebo
(a pill that looks exactly like the SSRI and the St. John's wort,
but has no active ingredients). The study participants who
responded positively were followed for an additional 18 weeks. At
the end of the first phase of the study, participants were
measured on two scales, one for depression and one for overall
functioning. There was no significant difference in rate of
response for depression, but the scale for overall functioning was
better for the antidepressant than for either St. John's wort or
placebo. While this study did not support the use of St. John's
wort in the treatment of major depression, ongoing NIH-supported
research is examining a possible role for St. John's wort in the
treatment of milder forms of depression.
The Food and Drug Administration issued a Public Health
Advisory on February 10, 2000. It stated that St. John's wort
appears to affect an important metabolic pathway that is used by
many drugs prescribed to treat conditions such as AIDS, heart
disease, depression, seizures, certain cancers, and rejection of
transplants. Therefore, health care providers should alert their
patients about these potential drug interactions.
Some other herbal supplements frequently used that have not
been evaluated in large-scale clinical trials are ephedra, gingko
biloba, echinacea, and ginseng. Any herbal supplement should be
taken only after consultation with the doctor or other health care
Many forms of psychotherapy, including some short-term (10-20
week) therapies, can help depressed individuals.
"Talking" therapies help patients gain insight into and
resolve their problems through verbal exchange with the therapist,
sometimes combined with "homework" assignments between
sessions. "Behavioral" therapists help patients learn
how to obtain more satisfaction and rewards through their own
actions and how to unlearn the behavioral patterns that contribute
to or result from their depression.
Two of the short-term psychotherapies that research has shown
helpful for some forms of depression are interpersonal and
cognitive/behavioral therapies. Interpersonal therapists focus on
the patient's disturbed personal relationships that both cause and
exacerbate (or increase) the depression. Cognitive/behavioral
therapists help patients change the negative styles of thinking
and behaving often associated with depression.
Psychodynamic therapies, which are sometimes used to treat
depressed persons, focus on resolving the patient's conflicted
feelings. These therapies are often reserved until the depressive
symptoms are significantly improved. In general, severe depressive
illnesses, particularly those that are recurrent, will require
medication (or ECT under special conditions) along with, or
preceding, psychotherapy for the best outcome.
HOW TO HELP YOURSELF IF YOU ARE DEPRESSED
Depressive disorders make one feel exhausted, worthless,
helpless, and hopeless. Such negative thoughts and feelings make
some people feel like giving up. It is important to realize that
these negative views are part of the depression and typically do
not accurately reflect the actual circumstances. Negative thinking
fades as treatment begins to take effect. In the meantime:
- Set realistic goals in light of the depression and assume a
reasonable amount of responsibility.
- Break large tasks into small ones, set some priorities, and
do what you can as you can.
- Try to be with other people and to confide in someone; it is
usually better than being alone and secretive.
- Participate in activities that may make you feel better.
- Mild exercise, going to a movie, a ballgame, or
participating in religious, social, or other activities may
- Expect your mood to improve gradually, not immediately.
Feeling better takes time.
- It is advisable to postpone important decisions until the
depression has lifted. Before deciding to make a significant
transition-change jobs, get married or divorced-discuss it
with others who know you well and have a more objective view
of your situation.
- People rarely "snap out of" a depression. But they
can feel a little better day-by-day.
- Remember, positive thinking will replace the negative
thinking that is part of the depression and will disappear as
your depression responds to treatment.
- Let your family and friends help you.
How Family and Friends Can Help the Depressed Person
The most important thing anyone can do for the depressed person
is to help him or her get an appropriate diagnosis and treatment.
This may involve encouraging the individual to stay with treatment
until symptoms begin to abate (several weeks), or to seek
different treatment if no improvement occurs. On occasion, it may
require making an appointment and accompanying the depressed
person to the doctor. It may also mean monitoring whether the
depressed person is taking medication. The depressed person should
be encouraged to obey the doctor's orders about the use of
alcoholic products while on medication. The second most important
thing is to offer emotional support. This involves understanding,
patience, affection, and encouragement. Engage the depressed
person in conversation and listen carefully. Do not disparage
feelings expressed, but point out realities and offer hope. Do not
ignore remarks about suicide. Report them to the depressed
person's therapist. Invite the depressed person for walks,
outings, to the movies, and other activities. Be gently insistent
if your invitation is refused. Encourage participation in some
activities that once gave pleasure, such as hobbies, sports,
religious or cultural activities, but do not push the depressed
person to undertake too much too soon. The depressed person needs
diversion and company, but too many demands can increase feelings
Do not accuse the depressed person of faking illness or of
laziness, or expect him or her "to snap out of it."
Eventually, with treatment, most people do get better. Keep that
in mind, and keep reassuring the depressed person that, with time
and help, he or she will feel better.