Mood

Depression FAQ - An Overview

Your definitive cheat sheet.

This depression FAQ is intended to give you an introductory overview of depression. The FAQ is divided into three parts. Part I discusses the nature of depression, its symptoms and causes, how it affects both mind and body, its impact on men, women, kids, and seniors, and seeking out treatment.

Part II focuses on medical and therapeutic treatments for depression including medications and talking therapy, while Part III looks at various recovery strategies.

What is depression?

Depression is a mood disorder characterized by a range of symptoms that may include feeling depressed most of the time, loss of pleasure, feelings of worthlessness, and suicidal thoughts, as well as physical states that may affect eating and sleeping and other activities.

What are the symptoms of depression?

The American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) lists nine symptoms for major depression, five or more which must be present over the same two-week period, including one of the first two: 1) Feeling depressed most of the day, nearly every day, or 2) Markedly diminished pleasure.

The other seven symptoms include: 3) Significant weight gain or loss, 4) Insomnia or hypersomnia, 5) psychomotor agitation or retardation, 6) Fatigue or loss of energy, 7) Feelings of worthlessness or inappropriate guilt, 8) Diminished ability to think or concentrate, 9) Recurrent thoughts of death, suicidal thinking, suicide attempts.

I only have four symptoms. Does that mean I don’t have major depression?

The DSM-IV is meant to be a guideline, and is not cast in stone. Moreover, your doctor or psychiatrist is likely to consider other factors in making a determination.

What do you mean by other factors?

The next edition of the DSM is scheduled for 2011, and there are bound to be many changes, based on what we have learned about depression since the DSM-IV came out in 1994 and the revised edition of the DSM-III which is very similar, which came out in 1987, and the original DSM-III on which modern psychiatry is based in 1980. For example, most people with depression also suffer from anxiety or panic. Anxiety used to be thought of as a separate illness, but psychiatry is reassessing that position, so the next DSM for depression is likely to have some kind of anxiety component. Also, most people with depression suffer from unexplained physical pain, which should arguably be included as an optional symptom (but is is unlikely to be). In fact, most people with depression go to their primary care physicians complaining of physical symptoms instead of saying they are depressed.

I have been told to snap out of it. Depression must be my fault, right?

Wrong. Depression is a medical illness which affects an organ, the brain, which in turn affects the rest of the body. One can no more snap out of depression that one can snap out of diabetes or heart disease. It would help to have a positive outlook, but the very nature of depression is a lack of positive outlook. Unfortunately, having depression still carries a stigma, though not nearly as bad as in the past. If there is any consolation, you are in good company: Winston Churchill, Abraham Lincoln, Peter Illych Tchaikovsky, Frederic Chopin, and Mike Wallace, just to name a few, all had crushing depressions.

Are there specific types of depression?

Yes. There is dysthymia, melancholic depression, atypical depression, bipolar depression, psychotic depression, catatonic depression, seasonal affective disorder, and postpartum depression.

What is dysthymia?

Dysthymia is chronic mild to moderate chronic depression, as opposed to major depression. The DSM-IV mandates the same symptoms as for major depression, except for suicidality, but requires only three symptoms in all, so long as they have persisted over two years. Mild to moderate is a misnomer, as dysthymia can make a person’s life as miserable as major depression.

What is melancholic depression?

Melancholic depression is major depression with an emphasis on lack of pleasure or lack of reactivity to pleasure. Other characteristics include (three or more): Depressed mood, depression at worst in the morning, early morning awakening, psychomotor agitation or retardation, significant weight loss, and inappropriate guilt.

What is atypical depression?

Atypical depression is a misnomer, as more outpatients suffer from atypical depression than from other forms of depression. Atypical depression is major depression that differs from melancholic depression in that patients react positively to external events, plus (two or more): Significant weight gain (as opposed to weight loss), hypersomnia (as opposed to insomnia), leaden paralysis, and sensitivity to personal rejection.

What is bipolar depression?

Bipolar depression is a feature of bipolar disorder, also known as manic depression, an illness characterized by mood swings from depression to mania. The diagnostic criteria for bipolar depression is the same as for major depression, but bipolar patients tend to have atypical features. Bipolar patients who rapid cycle can be up and down in a matter of minutes, and in mixed states depression and mania are present at once.

What is psychotic depression?

Psychotic depression is a rare form of depression characterized by delusions or hallucinations, such as believing you are someone you are not and hearing voices.

What is catatonic depression?

Catatonic depression is a rare form of major depression characterized by (at least two): Stupor, excessive motor activity, extreme negativism, peculiarities in voluntary movement, and repetition of other people's words or actions.

What is seasonal affective disorder?

Seasonal affective disorder is major depression that appears in the fall or winter and goes away in spring, thought to be caused by lack of sunlight.

What is postpartum depression?

Postpartum depression occurs within four weeks of a women giving childbirth. Most new mothers suffer from some form of the “baby blues.” Postpartum depression, by contrast, is major depression, thought to be triggered by changes in hormonal flows associated with childbirth.

Are women especially vulnerable to depression?

Yes. Besides postpartum depression, some women also experience depression as part of their hormonal cycle, referred to as premenstrual dysphoric disorder, or PMDD. Across all nations and cultures, it was found that twice as many women experience depression as men. The disparity starts as girls become teens, and it is thought that their concerns about social acceptance and fitting in have a lot to do with it. Moreover, the experts believe that women ruminate more than men, and that their lower socio-economic position gives them more reasons to be depressed.

So men get off lightly, right?

Wrong. A strong body of opinion posits that the DSM is biased toward women. For example, perhaps the most important symptom of depression - feeling depressed most of the time - lists as its only example "appears tearful." Men tend to express their inner hurt in other ways, such as anger, irritability, aggression, and antisocial behavior. Women eat for comfort, or not eat if they are worried (which is recognized as a symptom) while men tend to take solace in alcohol or drugs (which is not recognized as a symptom). This suggests that many men are not getting treated or are getting the wrong treatment. The next DSM may make some changes in this regard.

So depression is more than depression, then.

Exactly. Depression, in fact, is a very inapt word. Depression incorporates a wide range of emotions and behaviors, from feeling sad to loss of pleasure to being anxious to being angry to acting aggressively. Throw in out of whack sleeping and eating, loss of energy, not being able to think straight, and unexplained pain, and we are talking about a mental and physical hurricane.

Are there any other physical aspects of depression?

Yes. Mind and body are very much connected. The risk of heart disease is doubled in people with depression, and a previous depression is often the greatest risk factor for heart disease and other ills, over smoking, drinking, high blood sugar, and previous heart attacks. Depression has also been connected to diabetes, bone loss, stroke, irritable bowel syndrome, and possibly cancer. In addition, people with depression have much higher rates of alcohol and substance use than the general population.

What if I have depression and a substance/alcohol problem?

The Substance Abuse and Mental Health Services Administration recommends treating both illnesses simultaneously, ideally in an integrated setting in the same facility, at the very least with the different treatment providers working together.

What is the connection between depression and physical illness?

There are a number of possible smoking guns. One, people who are depressed are less likely to take care of themselves, more likely to engage in risky behavior such as bad diet, smoking, alcohol, and drugs, and are less likely to be compliant with treatment for their physical ills. Two, some of the body’s mental and physical processes are regulated by the same neurotransmitters. But the key intermediary between depression and physical ills is probably stress. Stress can be both a cause and a product of depression, and the stress hormone cortisol that floods the system during a depressive episode plays a key role in cell damage.

Just how serious a problem is depression?

According to the National Institute of Mental Health, approximately 18.8 million American adults, or about 9.5 percent of the US population age 18 and older in a given year, have a depressive disorder. According to the World Health Organization, depression is presently on track to becoming the world's second-most disabling disease (after heart disease) by the year 2020. In addition, depression is responsible for some $87 billion a year in lost productivity in the US (a conservative estimate), and according to Bank One, is responsible for most lost work days in its employees after pregnancy and childbirth. Additionally, one million people worldwide die by their own hand, most as a result of a mood disorder. Finally, the linkage between depression and a host of physical illnesses makes it arguably the world's greatest killer.

Can kids get depression?

Yes. Some 3.4 million Americans under age 18 are depressed, one in 33 children and one in eight teens. Depression can be especially damaging to kids due to the fact that a single episode of say six months can disrupt his or her entire school year. Fortunately kids respond to the same treatments and therapies, but parents need to be vigilant. There is a good deal of opposition to kids taking meds designed for adults, much of it valid. If an antidepressant is to be prescribed, a psychiatrist - ideally one who specializes in pediatrics - should be treating your child, not a family doctor. If a family doctor is your only option, find one with knowledge and experience in treating depressed kids.

What about the elderly?

Depression is not a normal part of aging. Older people may have more to be depressed about, but this is generally off-set by the range of coping skills they have picked up over their lifetimes. Unfortunately, depression in the elderly is very difficult to spot, as its symptoms are easy to confuse with other symptoms of age-related illnesses. Support is vital, with the rates of depression much higher in nursing homes than among the elderly in the community.

Are there any other considerations?

Absolutely. One is that we need to know if our depressions are chronic or recurrent.

What is the difference between chronic and recurrent depression?

Recurrent depressions tend to come and go - with shorter episodes - while chronic depressions may last for years, with no relief. Those with highly-recurrent depressions tend to cycle in a manner similar to bipolar disorder. Many experts feel that recurrent depression is a close cousin to bipolar disorder and should be treated in a similar fashion.

Are there other ways depression can resemble bipolar disorder?

Yes. Recent studies have found that many people with depression may have some features of mania or hypomania - not enough to change their diagnosis to bipolar but enough to make a clinical difference. These people may have depressions characterized by agitation, irritablity, and anger - road rage states. At present, the DSM only recognizes mixed mania, but mixed depression is also real.

So depression and bipolar could be part of the same phenomenon?

You got it. You may have heard of the "mood spectrum."

Tell me about the mood spectrum.

There are two main ways of looking at the mood spectrum: 1) Think of pure depression and one end and pure mania on the other, with features of both mixing it up in the middle. 2) Think of chronic depression on one end (with no cycling) and bipolar on the other end (with extreme cycling). In either case, we have a lot of overlap, with no clear boundaries. So you need to know exactly where you are on the spectrum at any given time, as this has huge implications for your treatment and recovery.

Who should I go to for my depression?

By default, your primary care physician is your first stop. But keep in mind, your doctor is not likely to pick up depression during the course of a typical physical exam. As one expert observed, it is easier for your PCP to order expensive and often unnecessary lab tests than to take five additional minutes talking to you. Even if your PCP does spot depression, a number of studies indicate that he or she fails to prescribe antidepressants in the right dose and over a sufficient length of time, and that there is rarely any follow-up. Keep in mind that getting an opening to see a psychiatrist may take several weeks, so you may be stuck with a PCP in the initial phase of your treatment.

Why should I seek out a psychiatrist?

Psychiatrists are trained to spot depression and its many subtleties, and to be on the alert for anxiety and substance use and other illnesses and behaviors that often occur with depression. During your first exam, he or she will ask detailed questions to verify certain suspicions and rule out others. Questions tend to range from your symptoms to how you are faring at work and at home to your family history of mental illness, if any.

What about seeking out a talking therapist?

A psychologist is also qualified to give you an examination and give you a diagnosis, but is not licensed to prescribe medications.

Isn't there a simple test to determine if a person has depression?

Unfortunately not. As we have seen, depression is at best an arbitrary designation for a host of symptoms that are likely to be revised for the next DSM. There is no depression bacteria or virus we can identify, nor do we have any kind of blood or lab test to determine if a person has depression. Until we learn more, all we have to go on are an individual’s symptoms. Treating depression is all about treating the symptoms, rather than the underlying disease.

Treating just the symptoms doesn't sound very satisfactory.

True, but this is the case for most physical illnesses as well, from heart disease to the common cold.

Can't brain scans determine if a person has depression?

PET scans, fMRIs, and EEGs can show us spectacular images of how certain parts of the brain are affected during depression, but we are a far cry from using these technologies as failsafe diagnostic instruments.

How is depression caused?

The short answer is we don't know. It is convenient to say it is caused by a chemical imbalance in the brain, but this is not entirely accurate, especially since we cannot pinpoint the exact chemicals. The expert consensus is that depression is the result of genes, biology, and the environment interacting with one another. We have yet to identify depression genes, though experts expect we will find several, each making a small contribution. The biology largely concerns how neurons in the brain communicate to one another, and the chemical actions that take place inside the neuron, plus various stress pathways. The environment part of the equation includes personal stress and trauma. Various studies have shown that victims of childhood sexual abuse, war refugees, low income women, and the poor are far more depressed than the general population. While it is true that all these populations have more to be depressed about, these studies indicate a lot more is going on, here.

Updated Feb 10, 2008

Just the FAQs, Jack

Depression-Overview

Depression-Treatment

Depression/Bipolar-Recovery

Bipolar-Overview

Bipolar-Treatment

Knowledge is Necessity

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