Depression is a state of low mood and aversion to activity. While often described as a dysfunction, there are also strong arguments for seeing depression as an adaptive defense mechanism. The Diagnostic and Statistical Manual of Mental Disorders defines a depressed person as experiencing feelings of sadness, helplessness and hopelessness. In traditional colloquy, “depressed” is often synonymous with “sad”, but both clinical depression and non-clinical depression can also refer to a conglomeration of more than one feeling. Biological influences of depression are varied, but may relate to malnutrition, heredity, hormones, seasons, stress, illness, drug or alcohol use, neurotransmitter malfunction, long-term exposure to dampness and mold, back injury, and to aerosol exposure. There are also correlations between long term sleep difficulties and depression. Up to 90% of patients with depression are found to have sleep difficulties. Depression is when a person has five or more symptoms of depression for at least 2 weeks. These symptoms include feeling sad, hopeless, worthless, or pessimistic. In addition, people with major depression often have behavior changes, such as new eating and sleeping patterns.
Symptoms
- Agitation, restlessness, and irritability
- Dramatic change in appetite, often with weight gain or loss
- Extreme difficulty concentrating
- Fatigue and lack of energy
- Feelings of hopelessness and helplessness
- Feelings of worthlessness, self-hate, and inappropriate guilt
- Inactivity and withdrawal from usual activities, a loss of interest or pleasure in activities that were once enjoyed (such as sex)
- Thoughts of death or suicide
- Trouble sleeping or excessive sleeping
Depression can be treated in a variety of ways, particularly with medications and counseling. Most people benefit from a combination of the two treatments. Some studies have shown that antidepressant drug therapy combined with psychotherapy has better results than either therapy alone.
As treatment takes effect, negative thinking diminishes. It takes time to feel better, but there are usually day-to-day improvements.
It is important to maintain a healthy lifestyle:
- Avoid alcohol and drugs (which make depression worse and may interfere with medications)
- Eat well-balanced meals
- Get regular exercise and sleep
- Seek supportive relationships
The outcome is usually good with treatment. Although most depressive episodes can be effectively treated with either medication, psychotherapy, or both, depression is a recurring problem for many people. For people who have experienced repeated episodes of depression, maintenance treatment may be needed to prevent future recurrences.
Management
The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy.
Psychotherapy is the treatment of choice for people under 18, while electroconvulsive therapy is only used as a last resort. Care is usually given on an outpatient basis, while treatment in an inpatient unit is considered if there is a significant risk to self or others. A significant number of recent studies have indicated that physical exercise has beneficial effects.
Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is often difficult. Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition.
Psychotherapy can be delivered, to individuals or groups, by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used. In people under 18, according to the National Institute for Health and Clinical Excellence, medication should only be offered in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy. Psychotherapy has been shown to be effective in older people. Successful psychotherapy appears to reduce the recurrence of depression even after it has been terminated or replaced by occasional booster sessions.
The most studied form of psychotherapy for depression is CBT, thought to work by teaching clients to learn a set of useful cognitive and behavioral skills. Earlier research suggested that CBT was not as effective as antidepressant medication; however, research beginning in the mid-1990s suggested that CBT could perform as well or better than antidepressants in patients with moderate to severe depression. CBT may be effective in depressed adolescents, although its effects on severe episodes might not be definitively known. Combining fluoxetine with CBT appeared to bring no additional benefit, or, at the most, only marginal benefit. Several variables predict success for cognitive behavior therapy in adolescents: higher levels of rational thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive distortions. CBT is particularly beneficial in preventing relapse. Several variants of cognitive behavior therapy have been used in depressed patients, most notably rational emotive behavior therapy, and more recently mindfulness-based cognitive therapy.
Interpersonal psychotherapy focuses on the social and interpersonal triggers that may cause depression. The therapy takes a structured course with a set number of weekly sessions (often 12) that focus on relationships with others. Therapy can be used to foster interpersonal skills that allow people to communicate more effectively and to reduce stress.
Psychoanalysis is a school of thought, founded by Sigmund Freud, which emphasizes the resolution of unconscious mental conflicts. Psychoanalytic techniques are used by some practitioners to treat clients presenting with major depression. A more widely practiced, eclectic technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus. In a meta-analysis of three controlled trials of Short Psychodynamic Supportive Psychotherapy, this modification was found to be as effective as medication for mild to moderate depression.
Logotherapy, a form of existential psychotherapy developed by Austrian psychiatrist Viktor Frankl, addresses the filling of an “existential vacuum” associated with feelings of futility and meaninglessness. It is posited that this type of psychotherapy may be useful for depression in older adolescents.
Medication
Antidepressants and the effects of prescription antidepressants can be comparable to those of psychotherapy, although more patients cease medication than cease psychotherapy, most likely due to adverse effects from the medication.
To find the most effective antidepressant medication with minimal side effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. Response rates to the first antidepressant administered range from 50–75%, and it can take at least six to eight weeks from the start of medication to remission, when the patient is back to their normal self. Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to 1 year of continuation is recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.
Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, escitalopram, fluoxetine, paroxetine, and citalopram are the primary medications prescribed owing to their effectiveness, relatively mild side effects, and because they are less toxic in overdose than other antidepressants. Patients who do not respond to one SSRI can be switched to another, and this results in improvement in almost 50% of cases. Another option is to switch to the atypical antidepressant bupropion. Venlafaxine, an antidepressant with a different mechanism of action, may be modestly more effective than SSRIs. However, venlafaxine is not recommended in the UK as a first-line treatment because of evidence suggesting its risks may outweigh benefits, and it is specifically discouraged in children and adolescents. For adolescent depression, fluoxetine and escitalopram are the two recommended choices. Antidepressants have not been found to be beneficial in children. Any antidepressant can cause low serum sodium levels (also called hyponatremia); nevertheless, it has been reported more often with SSRIs. It is not uncommon for SSRIs to cause or worsen insomnia; the sedating antidepressant mirtazapine can be used in such cases.
Monoamine oxidase inhibitors, an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better tolerated agents of this class have been developed.
The terms “refractory depression” and “treatment-resistant depression” are used to describe cases that do not respond to adequate courses of at least two antidepressants. In many major studies, only about 35% of patients respond well to medical treatment. It may be difficult for a doctor to decide when someone has treatment-resistant depression or whether the problem is due to coexisting disorders, which are common among patients with major depression.
Electroconvulsive therapy (ECT) is a procedure whereby pulses of electricity are sent through the brain via two electrodes, usually one on each temple, to induce a seizure while the patient is under a short general anaesthetic. Hospital psychiatrists may recommend ECT for cases of severe major depression which have not responded to antidepressant medication or, less often, psychotherapy or supportive interventions. ECT can have a quicker effect than antidepressant therapy and thus may be the treatment of choice in emergencies such as catatonic depression where the patient has stopped eating and drinking, or where a patient is severely suicidal. ECT is probably more effective than pharmacotherapy for depression in the immediate short-term, although a landmark community-based study found much lower remission rates in routine practice. Used on its own the relapse rate within the first six months is very high; early studies put the rate at around 50%, while a more recent controlled trial found rates of 84% even with placebos. The early relapse rate may be reduced by the use of psychiatric medications or further ECT (although the latter is not recommended by some authorities) but remains high. Common initial adverse effects from ECT include short and long-term memory loss, disorientation and headache. Although objective psychological testing shows memory disturbance after ECT has mostly resolved by one month post treatment, ECT remains a controversial treatment, and debate on the extent of cognitive effects and safety continues.
Physical exercise is recommended by U.K. health authorities, and a systematic review of 23 studies indicated a “large clinical effect”. Among these, three studies employing intention to treat analysis and other bias-reducing measures were inconclusive. Its benefits are most statistically significant in mild to moderate forms of depression and anxiety.
St John’s wort is available over-the-counter as a herbal remedy in some parts of the world; however, the evidence of its effectiveness for the treatment of major depression is varying and confusing. Its safety can be compromised by inconsistency in pharmaceutical quality and in the amounts of active ingredient in different preparations. Further, it interacts with numerous prescribed medicines including antidepressants, and it can reduce the effectiveness of hormonal contraception.
Repetitive transcranial magnetic stimulation (rTMS) applies powerful magnetic fields to the brain from outside the head. Multiple controlled studies support the use of this method in treatment-resistant depression; it has been approved for this indication in Europe, Canada, Australia, and the US. rTMS appeared similarly effective for both uncomplicated depression and depression resistant to medication; however, it was inferior to ECT in a side-by-side randomized trial.