depression (also called severe depressive disorder,
major depressive disorder) is a state of intense sadness,
melancholia or despair that has advanced to the point
of being disruptive to an individual's social functioning
and/or activities of daily living. Although a low
mood or state of dejection that does not affect functioning
is often referred to as depression, clinical depression
is a clinical diagnosis and may be different from
the everyday meaning of "being depressed".
Many people identify this feeling as "being blue",
"feeling sad for no reason", or "having
no motivation to do anything".
The Ebers papyrus (ca 1550 BC) contains a short description
of clinical depression. Though full of incantations
and foul applications meant to turn away disease-causing
demons and other superstition, it also evinces a long
tradition of empirical practice and observation.
modern idea of depression appears similar to the much
older concept of melancholia. The name melancholia
derives from "black bile", one of the "four
humours" postulated by Galen.
depression was originally considered to be a chemical
imbalance in transmitters in the brain, a theory based
on observations made in the 1950s of the effects of
reserpine and isoniazid in altering monoamine neurotransmitter
levels and affecting depressive symptoms. Since
these suggestions, many other causes for clinical
depression have been proposed.
Clinical depression affects about 16% of the population
on at least one occasion in their lives. In some countries,
such as Australia, one in four women and one in six
men will suffer from depression. The mean age of onset,
from a number of studies, is in the late 20s. About
twice as many females as males report or receive treatment
for clinical depression, though this imbalance is
shrinking over the course of recent history; this
difference seems to completely disappear after the
age of 50 - 55, when most females have passed the
end of menopause. It should be noted that these numbers
are only for those who report or receive treatment
for depression; Due to gender roles, men are less
likely to report feeling depressed, and also less
likely to seek treatment. Clinical depression is currently
the leading cause of disability in the U.S. as well
as other countries, and is expected to become the
second leading cause of disability worldwide (after
heart disease) by the year 2020, according to the
World Health Organization.
A diagnosis is made when an individual meets a sufficient
number of the symptom criteria for the depression
spectrum as suggested in the DSM-IV-TR or ICD-9/ICD-10.
An individual is often seen to suffer from what is
termed as a "clinical depression" without
fully meeting the various criteria advanced for a
specific diagnosis on the depression spectrum. Possible
causes of depression are not taken into account in
diagnosis, unless it may be due to an existing medical
is important to understand that there is no blood
test or brain scan for depression. Therefore the term
"clinical depression" can be misleading
to those who erroneously believe that there is a medical
test for this disorder. Laboratory tests can provide
medical data for diseases such as diabetes and heart
disease, but currently not for depression, bipolar
disorder, schizophrenia and other mental disorders.
According to the DSM-IV-TR criteria for diagnosing
a major depressive disorder (cautionary statement)
one of the following two elements must be present
for a period of at least two weeks:
It is sufficient to have either of these symptoms
in conjunction with five of a list of other symptoms
over a two-week period. These include:
of overwhelming sadness and/or fear, or the seeming
inability to feel emotion (emptiness).
A decrease in the amount of interest or pleasure in
all, or almost all, daily activities.
Changing appetite and marked weight gain or loss.
Disturbed sleep patterns, such as insomnia, loss of
REM sleep, or excessive sleep (Hypersomnia).
Psychomotor agitation or retardation nearly every
Fatigue, mental or physical, also loss of energy.
Intense feelings of guilt, helplessness, hopelessness,
worthlessness, isolation/loneliness and/or anxiety.
Trouble concentrating, keeping focus or making decisions
or a generalized slowing and obtunding of cognition,
Recurrent thoughts of death (not just fear of dying),
desire to just "lay down and die" or "stop
breathing", recurrent suicidal ideation without
a specific plan, or a suicide attempt or a specific
plan for committing suicide.
Feeling and/or fear of being abandoned by those close
Other symptoms often reported but not usually taken
into account in diagnosis include:
A decrease in self-esteem.
Inattention to personal hygiene.
Sensitivity to noise.
Physical aches and pains, and the belief these may
be signs of serious illness.
Fear of 'going mad'.
Change in perception of time.
Periods of sobbing.
Possible behavioral changes, such as aggression and/or
Depression in children is not as obvious as it is
in adults. Here are some symptoms that children might
Sleep problems, such as recurrent nightmares.
Learning or memory problems where none existed before.
Significant behavioral changes; such as withdrawal,
social isolation, and aggression.
An additional indicator could be the excessive use
of drugs or alcohol. Depressed adolescents are at
particular risk of further destructive behaviours,
such as eating disorders and self-harm.
of the most widely used instruments for measuring
depression severity is the Beck Depression Inventory,
a 21-question multiple choice survey.
is hard for people who have not experienced clinical
depression, either personally or by regular exposure
to people suffering it, to understand its emotional
impact and severity, interpreting it instead as being
similar to "having the blues" or "feeling
down." As the list of symptoms above indicates,
clinical depression is a serious, potentially lethal
systemic disorder characterized by the psychiatric
industry as interlocking physical, affective, and
cognitive symptoms that have consequences for function
and survival well beyond sad or painful feelings.
Mnemonics commonly used to remember the DSM-IV criteria
are SIGECAPS (sleep, interest (anhedonia), guilt,
energy, concentration, appetite, psychomotor, suicidality)
and DEAD SWAMP (depressed mood, energy, anhedonia,
death (thoughts of), sleep, worthlessness/guilt, appetite,
Types of depression
The diagnostic category major depressive disorder
appears in the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association.
The term is generally not used in countries which
instead use the ICD-10 system, but the diagnosis of
depressive episode is very similar to an episode of
major depression. Clinical depression also usually
refers to acute or chronic depression severe enough
to need treatment. Minor depression is a less-used
term for a subclinical depression that does not meet
criteria for major depression but where there are
at least two symptoms present for two weeks.
Major clinical depression
Major Depression, or, more properly, Major Depressive
Disorder (MDD), is characterized by a severely depressed
mood that persists for at least two weeks. Major Depressive
Disorder is specified as either "a single episode"
or "recurrent"; periods of depression may
occur as discrete events or as recurrent over the
lifespan. Episodes of major or clinical depression
may be further divided into mild, major or severe.
Where the patient has already had an episode of mania
or markedly elevated mood, a diagnosis of bipolar
disorder (also called bipolar affective disorder)
is usually made instead of MDD; depression without
periods of elation or mania is therefore sometimes
referred to as unipolar depression because their mood
remains on one pole. The diagnosis also usually excludes
cases where the symptoms are a normal result of bereavement.
recognize several possible subtypes of Major Depressive
Disorder. ICD-10 does not specify a melancholic subtype,
but does distinguish on presence or absence of psychosis.
with Catatonic Features - This subtype can be applied
to Major Depressive episodes as well as to manic episodes,
though it is rare, and rarer in mania. Catatonia is
characterized by motoric immobility evidenced by catalepsy
or stupor. This MDD subtype may also manifest excessive,
nonprompted motor activity (akathisia), extreme negativism
or mutism, and peculiarities in movement, including
stereotypical movements, prominent mannerisms, and
prominent grimacing. There may also be evidence of
echolalia or echopraxia. It is very rarely encountered,
and may not be a useful category.
Depression with Melancholic Features - Melancholia
is characterized by a loss of pleasure (anhedonia)
in most or all activities, a failure of reactivity
to pleasurable stimuli, a quality of depressed mood
more pronounced than that of grief or loss, a worsening
of symptoms in the morning hours, early morning waking,
psychomotor retardation, anorexia (excessive weight
loss, not to be confused with Anorexia Nervosa), or
Depression with Atypical Features - Atypicality is
characterized by mood reactivity (paradoxical anhedonia)
and positivity, significant weight gain or increased
appetite, excessive sleep or somnolence (hypersomnia),
leaden paralysis, or significant social impairment
as a consequence of hypersensitivity to perceived
interpersonal rejection. People suffering from this
subtype can react with interest or pleasure to some
things, unlike most depressed individuals.
Depression with Psychotic Features - Some people with
Major Depressive or Manic episode may experience psychotic
features. They may be presented with hallucinations
or delusions that are either mood-congruent (content
coincident with depressive themes) or non-mood-congruent
(content not coincident with depressive themes). It
is clinically more common to encounter a delusional
system as an adjunct to depression than to encounter
hallucinations, whether visual or auditory.
Other categories of depression
Dysthymia is a long-term, mild depression that lasts
for a minimum of two years. There must be persistent
depressed mood continuously for at least two years.
By definition the symptoms are not as severe as with
Major Depression, although those with Dysthymia are
vulnerable to co-occurring episodes of Major Depression.
This disorder often begins in adolescence and crosses
the lifespan. People who are diagnosed with major
depressive episodes and dysthymic disorder are diagnosed
with double depression. Dysthymic disorder develops
first and then one or more major depressive episodes
I Disorder is an episodic illness in which moods may
cycle between mania and depression. In the United
States, Bipolar Disorder was previously called Manic
Depression. This term is no longer favored by the
medical community, however, even though depression
plays a much stronger (in terms of disability and
potential for suicide) role in the disorder. "Manic
Depression" is still often used in the non-medical
II Disorder is an episodic illness that is defined
primarily by depression but evidences episodes of
Depression or Post-Natal Depression is clinical depression
that occurs within two years of childbirth. Owing
to physical, mental and emotional exhaustion combined
with sleep-deprivation, motherhood can "set women
up", so to speak, for clinical depression.
dysphoriais is a pattern of recurrent depressive symptoms
tied to the menstrual cycle. The premenstrual decline
in brain serotonin function is strongly correlated
with the concomitant worsening of self-rated cardinal
mood symptoms. Of considerable clinical importance,
the recent understanding of premenstrual dysphoria
as depression points directly to effective treatment
with Selective serotonin reuptake inhibitor (SSRI)
antidepressants. Previously, disrupting ovarian cyclicity
had been the only recognized treatment. A recent review
of studies of a number of SSRIs has revealed that
they can effectively ameliorate symptoms of premenstrual
dysphoria and may actually work best when taken only
during the part of the menstrual cycle when dysphoric
symptoms are evident.
The role of anxiety in depression
The different types of Depression and Anxiety are
classified separately by the DSM-IV-TR, with the exception
of hypomania, which is included in the bipolar disorder
category. Despite the different categories, depression
and anxiety can indeed be co-occurring (occurring
together, independently, and without mood congruence),
or comorbid (occurring together, with overlapping
symptoms, and with mood congruence). In an effort
to bridge the gap between the DSM-IV-TR categories
and what clinicians actually encounter, experts such
as Herman Van Praag of Maastricht University have
proposed ideas such as anxiety/aggression-driven depression
. This idea refers to an anxiety/depression
spectrum for these two disorders, which differs from
the mainstream perspective of discrete diagnostic
there is no specific diagnostic category for the comorbidity
of depression and anxiety in the DSM or ICD, the National
Comorbidity Survey (US) reports that 58 percent of
those with major depression also suffer from lifetime
anxiety. Supporting this finding, two widely accepted
clinical colloquialisms include
depression - a state of depression that presents as
anxiety and includes akathisia, suicide, insomnia
(not early morning wakefulness), nonclinical (meaning
"doesn't meet the standard for formal diagnosis")
and nonspecific panic, and a general sense of dread.
akathitic depression - a state of depression that
presents as anxiety or suicidality and includes akathisia
but does not include symptoms of panic.
It is also clear that even mild anxiety symptoms can
have a major impact on the course of a depressive
illness, and the commingling of any anxiety symptoms
with the primary depression is important to consider.
A pilot study by Ellen Frank et al., at the University
of Pittsburgh, found that depressed or bipolar patients
with lifetime panic symptoms experienced significant
delays in their remission. These patients also had
higher levels of residual impairment, or the ability
to get back into the swing of things. On a similar
note, Robert Sapolsky of Stanford University and others
also argue that the relationship between stress, anxiety,
and depression could be measured and demonstrated
biologically. To that point, a study by Heim and
Nemeroff et al., of Emory University, found that depressed
and anxious women with a history of childhood abuse
recorded higher heart rates and the stress hormone
ACTH when subjected to stressful situations.
Hypomania, as the name suggests, is a state of mind
or behavior that is "below" (hypo) mania.
In other words, a person in a hypomanic state often
displays behavior that has all the hallmarks of a
full-blown mania (e.g., marked elevation of mood that
is characterized by euphoria, over activity, disinhibition,
impulsivity, a decreased need for sleep, hypersexuality),
but these symptoms, though disruptive and seemingly
out of character, are not so pronounced as to be considered
a diagnosably manic episode. In a psychiatric context,
it is important to identify the possible presence
and characteristics of manic and hypomanic episodes,
since these may lead to a diagnosis of bipolar disorder,
which is medically treated differently from depression.
important point is that hypomania is a diagnostic
category that includes both anxiety and depression.
It often presents as a state of anxiety that occurs
in the context of a clinical depression. Patients
in a hypomanic state often describe a sense of extreme
generalized or specific anxiety, recurring panic attacks,
night terrors, guilt, and agency (as it pertains to
codependence and counterdependence). All of this happens
while they are in a state of retarded or somnolent
depression. This is the type of depression in which
a person is lethargic and unable to move through life.
The terms retarded and somnolent are shorthand for
states of depression that include lethargy, hypersomnia,
a lack of motivation, a collapse of ADLs (activities
of daily living), and social withdrawal. This is similar
to the shorthand used to describe an "agitated"
or "akathitic" depression.
considering the hypomania-depression connection, a
distinction should be made between anxiety, panic,
and stress. Anxiety is a physiological state that
is caused by the sympathetic nervous system. Anxiety
does not need an outside influence to occur. Panic
is related to the "fight or flight" mechanism.
It is a reaction, induced by an outside stimulus,
and is a product of the sympathetic nervous system
and the cerebral cortex. More plainly, panic is an
anxiety state that we are thinking about. Finally,
stress is a psychosocial reaction, influenced by how
a person filters nonthreatening external events. This
filtering is based on one's own ideas, assumptions,
and expectations. Taken together, these ideas, assumptions,
and expectations are called social constructionism.
a final note, researchers at the University of California,
San Diego, under the guidance of Hagop Akiskal MD,
have found convincing evidence for the co-occurrence
of hypomanic symptoms associated with a diagnosis
of depression where the diagnosis does not meet criteria
for Bipolar Disorder. Symptoms under
consideration, such as irritability, misdirected anger,
and compulsivity, also may not present sufficiently
to be considered a hypomanic episode, as described
by a Bipolar II Disorder. As noted in the Frank study
 mentioned above, this particular
course of the disease, with the breakthrough of anxiety,
may have a significant impact on the overall course
of the depression.
idea of co-occurring anxiety and depression is supported
in a study by Giovanni Cassano MD of the University
of Pisa and his collaborators on the Spectrum Project,
who found a correlation between lifetime hypomanic
and manic symptoms and the severity of the depression.[citation
presence of a significant number of manic/hypomanic
items in patients with recurrent unipolar depression
seems to challenge the traditional unipolar-bipolar
These authors, along with many other researchers,[citation
needed] argue in support of a revision of the approach
to psychiatric diagnosis into what is being called
the mood spectrum, so as to "[make] more accurate
diagnostic evaluation[s]." This approach, although
controversial, has begun to be given consideration
by many behavioral health professionals.
Causes of depression
No specific cause for depression has been identified,
but a number of factors are believed to be involved.
The tendency to develop depression may be inherited;
there is some evidence that this disorder may run
in families. A 2004 press release from the National
Institute of Mental Health declares "major depression
is thought to be 40-70 percent heritable, but likely
involves an interaction of several genes with environmental
There may be changes or imbalances in chemicals
that transmit information in the brain, called neurotransmitters.
Many modern antidepressant drugs increase levels of
certain neurotransmitters, such as serotonin and norepinephrine.
Although the causal relationship is unclear, it is
known that antidepressant medications can relieve
certain symptoms of depression, although critics point
out that the relationship between serotonin, SSRIs,
and depression usually is typically greatly oversimplified
when presented to the public (see here). Recent research
has suggested that there may be a link between depression
and neurogenesis of the hippocampus. This horseshoe-shaped
structure is a center for both mood and memory. Loss
of neurons in the hippocampus is found in depression
and correllates with impaired memory and dysthemic
mood. The hippocampus regains mass when exposed to
treatments that increase brain serotonin, and when
regrown, mood and memory tend to be restored.
Seasonal affective disorder (SAD) is a type of depressive
disorder that occurs in the winter when daylight hours
are short. It is believed that the body's production
of melatonin, which is produced at higher levels in
the dark, plays a major part in the onset of SAD and
that many sufferers respond well to bright light therapy,
also known as phototherapy.
Psychological factors Low self-esteem and self-defeating
or distorted thinking are connected with depression.
Although it is not clear which is the cause and which
is the effect, it is known that depressed persons
who are able to make corrections in their thinking
patterns can show improved mood and self-esteem.[citation
needed] Psychological factors related to depression
include the complex development of one's personality
and how one has learned to cope with external environmental
factors such as stress.
Early experiences Events such as the death
of a parent, abandonment or rejection, neglect, chronic
illness, and physical, psychological, or sexual abuse
can also increase the likelihood of depression later
in life. Post-traumatic stress disorder (PTSD) includes
depression as one of its major symptoms.
Life experiences Job loss, poverty, financial
difficulties, gambling addiction, long periods of
unemployment, the loss of a spouse or other family
member, divorce or the end of a committed relationship,
involuntary celibacy, or other traumatic events may
trigger depression. Long-term stress at home, work,
or school can also be involved. Bullying in late adolescence
is also thought to be a contributing factor.
Medical conditions Certain illnesses, including
cardiovascular disease, hepatitis, mononucleosis,
hypothyroidism, and organic brain damage caused by
degenerative conditions such as Parkinson disease,
Multiple Sclerosis or by traumatic blunt force injury
may contribute to depression, as may certain prescription
drugs such as birth control pills and steroids. Gender
dysphoria can also cause depression.
Diet The increase in depression in industrialised
societies has been linked to diet, particularly to
reduced levels of omega-3 fatty acids in intensively
farmed food and processed foods. This link has
been at least partly validated by studies using dietary
supplements in schools and by a double-blind test
in a prison. An excess of omega-6 fatty acids in the
diet was shown to cause depression in rats].
Alcohol and other drugs Alcohol can have a
negative effect on mood, and misuse of alcohol, benzodiazepine-based
tranquilizers, and sleeping medications can all play
a major role in the length and severity of depression.
Postpartum depression (also known as postnatal depression)
Dr. Ruta M Nonacs writes that while many women
experience some mood changes after giving birth, "10-15%
of women experience a more disabling and persistent
form of mood disturbance (eg, postpartum depression,
postpartum psychosis)."  When it occurs, the
onset typically is within three months after delivery,
and it may last for several months. About two new
mothers out of a thousand experience the more serious
depressive disorder Postnatal Psychosis which includes
hallucinations and/or delusions.
Living with a depressed person Those living
with someone suffering from depression experience
increased anxiety and life disruption, increasing
the possibility of also becoming depressed.[citation
Evolutionary biological hypotheses of depression
Evolutionary analyses usually consider possible functions
for depressed mood as well as clinical depression.
The psychic pain hypothesis: psychic pain, such as
depression, is analogous to physical pain. The function
of physical pain is to inform the organism that it
is suffering damage, to motivate it to withdraw from
the source of damage, and to learn to avoid such damage-causing
circumstances in the future. Analogously, depression
informs the sufferer that current circumstances, such
as the loss of a mate, are imposing a threat to biological
fitness, it motivates the sufferer to cease activities
that led to the costly situation, if possible, and
it causes him or her to learn to avoid similar circumstances
in the future. Proponents of this view tend to focus
on low mood, and regard clinical depression as a dysfunctional
extreme of low mood. See, e.g., Nesse 2000 and Keller
and Nesse 2005; see also Hagen and Barrett n.d..
Rank theory: If an individual is involved in a lengthy
fight for dominance in a social group and is clearly
losing, depression causes the individual to back down
and accept the submissive role. In doing so, the individual
is protected from unnecessary harm. In this way, depression
helps maintain a social hierarchy. This theory is
a special case of a more general theory derived from
the psychic pain hypothesis: that the cognitive response
that produces modern-day depression evolved as a mechanism
that allows people to assess whether they are in pursuit
of an unreachable goal, and if they are, to motivate
them to desist. See, e.g., Nesse 2000.
Honest signalling theory: When social partners have
conflicts of interest, 'cheap' signals of need, such
as crying, might not be believed. Biologists and economists
have proposed that signals with inherent costs can
credibly signal information when there are conflicts
of interest. The symptoms of major depression, such
as loss of interest in virtually all activities and
suicidality, are inherently costly, but, as costly
signaling theory requires, the costs differ for individuals
in different states. For individuals who are not genuinely
in need, the fitness cost of major depression is very
high because it threatens the flow of fitness benefits.
For individuals who are in genuine need, however,
the fitness cost of major depression is low because
the individual is not generating many fitness benefits.
Thus, only an individual in genuine need can afford
to suffer major depression. Major depression therefore
serves as an honest, or credible, signal of need.
See, e.g., Hagen 2003, Watson and Andrews 2002.
Social navigation or niche change theory: The social
navigation, bargaining, or niche change hypothesis
 suggests that depression, operationally defined
as a combination of prolonged anhedonia and psychomotor
retardation or agitation, provides a focused sober
perspective on socially imposed constraints hindering
a persons pursuit of major fitness enhancing
projects. Simultaneously, publicly displayed symptoms,
which reduce the depressive's ability to conduct basic
life activities, serve as a social signal of need;
the signal's costliness for the depressive certifies
its honesty. Finally, for social partners who find
it uneconomical to respond helpfully to an honest
signal of need, the same depressive symptoms also
have the potential to extort relevant concessions
and compromises. Depressions extortionary power
comes from the fact that it retards the flow of just
those goods and services such partners have come to
expect from the depressive under status quo socioeconomic
Thus depression may be a social adaptation especially
useful in motivating a variety of social partners,
all at once, to help the depressive initiate major
fitness-enhancing changes in their socioeconomic life.
There are extraordinarily diverse circumstances under
which this may become necessary in human social life,
ranging from loss of rank or a key social ally which
makes the current social niche uneconomic to having
a set of creative new ideas about how to make a livelihood
which begs for a new niche. The social navigation
hypothesis emphasizes that an individual can become
tightly ensnared in an overly restrictive matrix of
social exchange contracts, and that this situation
sometimes necessitates a radical contractual upheaval
that is beyond conventional methods of negotiation.
Regarding the treatment of depression, this hypothesis
calls into question any assumptions by the clinician
that the typical cause of depression is related to
maladaptive perverted thinking processes or other
purely endogenous sources. The social navigation hypothesis
calls instead for a penetrating analysis of the depressives
talents and dreams, identification of relevant social
constraints (especially those with a relatively diffuse
non-point source within the social network of the
depressive), and practical social problem-solving
therapy designed to relax those constraints enough
to allow the depressive to move forward with their
life under an improved set of social contracts.
theory: This theory is similar to the honest signaling,
niche change, and social navigation theory. It basically
adds one additional element to honest signaling theory.
The fitness of social partners is generally correlated.
When a wife suffers depression and reduces her investment
in offspring, for example, the husband's fitness is
also put at risk. Thus, not only do the symptoms of
major depression serve as costly and therefore honest
signals of need, they also compel social partners
to respond to that need in order to prevent their
own fitness from being reduced. See, e.g., Hagen 1999,
Treatment of depression varies broadly and is different
for each individual. Various types and combinations
of treatments may have to be tried. There are two
primary modes of treatment, typically used in conjunction:
medication and psychotherapy. A third treatment, electroconvulsive
therapy (ECT), may be used when chemical treatment
alternative treatments used for depression include
exercise and the use of vitamins, herbs, or other
nutritional supplements.
effectiveness of treatment often depends on factors
such as the amount of optimism and hope the sufferer
is able to maintain, the control s/he has over stressors,
the severity of symptoms, the amount of time the sufferer
has been depressed, the results of previous treatments,
and the degree of support of family, friends, and
significant others.
treatment is generally effective,
in some cases the condition does not respond. Treatment-resistant
depression warrants a full assessment, which may lead
to the addition of psychotherapy, higher medication
dosages, changes of medication or combination therapy,
a trial of ECT/electroshock, or even a change in the
diagnosis, with subsequent treatment changes. Although
this process helps many, some people's symptoms continue
emergencies, psychiatric hospitalization is used simply
to keep suicidal people safe until they cease to be
dangers to themselves. Another treatment program is
partial hospitalization, in which the patient sleeps
at home but spends the day, either five or seven days
a week, in a psychiatric hospital setting in intense
treatment. This treatment usually involves group therapy,
individual therapy, psychopharmacology, and academics
(in child and adolescent programs).
Medication that relieves the symptoms of depression
has been available for several decades. These drugs
are listed in order of historical development. Typical
first-line therapy for depression is the use of an
selective serotonin reuptake inhibitor, such as sertraline
(Zoloft). Medication is generally prescribed in combination
with psychotherapy, as research has indicated this
is the most effective treatment regimen for depression.
oxidase inhibitors (MAOIs) such as Nardil may be used
if other antidepressant medications are ineffective.
Because there are potentially fatal interactions between
this class of medication and certain foods and drugs,
they are rarely prescribed anymore. MAOI's are used
to block the enzyme monoamine oxidase which breaks
down neurotransmitters such as serotonin and norepinephrine.
MAOI's are as effective as tricyclics, if not slightly
more effective. A new MAOI has recently been introduced.
Moclobemide (Manerix), known as a reversible inhibitor
of monoamine oxidase A (RIMA), follows a very specific
chemical pathway and does not require a special diet.
antidepressants are the oldest and include such medications
as amitriptyline and desipramine. Tricyclics block
the reuptake of certain neurotransmitters such as
norepinephrine and serotonin. They are used less commonly
now because of their side effects, which include increased
heart rate, drowsiness, dry mouth,constipation, urinary
retention, blurred vision,dizziness, confusion, and
sexual dysfunction. Most importantly, they have a
high potential to be lethal in moderate overdose.
However, tricyclic antidepressants are still used
because of their high potency, especially in severe
cases of clinical depression.
serotonin reuptake inhibitors (SSRIs) are a family
of antidepressant considered to be the current standard
of drug treatment. It is thought that one cause of
depression is an inadequate amount of serotonin, a
chemical used in the brain to transmit signals between
neurons. SSRIs are said to work by preventing the
reabsorption of serotonin by the nerve cell, thus
maintaining the levels the brain needs to function
effectively, although two researchers recently demonstrated
that this is a marketing technique rather than a scientific
portrayal of how the drugs actually work. . Recent
research indicates that these drugs may interact with
transcription factors known as "clock genes",
which may be important for the addictive properties
of drugs of abuse and possibly in obesity.
family of drugs includes fluoxetine (Prozac), paroxetine
(Paxil), escitalopram (Lexapro), citalopram (Celexa),
and sertraline (Zoloft). These antidepressants typically
have fewer adverse side effects than the tricyclics
or the MAOIs, although such effects as drowsiness,
dry mouth, nervousness, anxiety, insomnia, decreased
appetite, and decreased ability to function sexually
may occur. Some side effects may decrease as a person
adjusts to the drug, but other side effects may be
reuptake inhibitors such as reboxetine (Edronax) act
via norepinephrine (also known as noradrenaline).
NeRIs are thought to have a positive effect on concentration
and motivation in particular. Drugs such as Bupropion
can help with smoking cessation. It is also known
to inhibit the neuronal reuptake of dopamine.
reuptake inhibitors (SNRIs) such as venlafaxine (Effexor)
and duloxetine (Cymbalta) are a newer form of antidepressant
that works on both noradrenaline and serotonin. They
typically have similar side effects to the SSRIs,
although there may be a withdrawal syndrome on discontinuation
that may necessitate dosage tapering.
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5-HTP supplements are claimed to provide more raw
material to the body's natural serotonin production
process. There is a reasonable indication that 5-HTP
may not be effective for those who haven't already
responded well to an SSRI. 
methionine (SAM-e) is a derivative of the amino acid
methionine that is found throughout the human body,
where it acts as a methyl donor and participates in
other biochemical reactions. It is available as a
prescription antidepressant in Europe and an over-the-counter
dietary supplement in the United States. Clinical
trials have shown SAM-e to be as effective as standard
antidepressant medication, with fewer side effects;
however, some studies have reported an increased incidence
of mania resulting from SAM-e use compared to other
antidepressants. Its mode of action is unknown.
fatty acids (found naturally in oily fish, flax seeds,
hemp seeds, walnuts, and canola oil) have also been
found to be effective when used as a dietary supplement
(although only fish-based omega-3 fatty acids have
shown antidepressant efficacy .
(DHEA), available as a supplement in the U.S., raises
serotonin levels.
improves mood, probably by raising serotonin.[citation
has gathered some attention .
John's Wort [Hypericum perforatum] Traditionally used
by 'wise women' and midwives for hundreds of years,
to 'chase away the devil' of melancholia and anxiety.
It is a mood-enhancing antidepressant supplement that
increases the availability of serotonin, norepinephrine
and dopamine at the neuron synapses. Also popular
for treating insomnia, mood swings, fatigue, PMS and
Biloba Effective natural antidepressant  said
to stabilise cell membranes, inhibiting lipid breakdown
and aiding cell use of oxygen and glucose - so subsequently
a mental and vascular stimulant that improves neurotransmitter
production. Also popular for treating mental concentration
(such as for Alzheimer's and stroke patients).
Ginseng [Eleutherococcus senticosus] Although not
a true panax ginseng it is a mood enhancement supplment
against stress. Also popular for treating depression,
insomnia, moodiness, fatigue, poor memory, lack of
focus, mental tension and endurance.
25mg per day have had an antidepressant effect in
an experiment .
a deficiency has caused a severe depression. The patient's
symptoms improved after the deficiency was corrected.
B-12: Symptoms of a vitamin B-12 deficiency can include
depression and other psychiatric disorders.[citation
amino acids phenylalanine and tyrosine have also a
favorable effect on easy forms of depression. They
enhance the neurotransmitters dopamine and noradrenalin.[citation
Some antidepressants have been found to work more
effectively in some patients when used in combination
with another drug. Such "augmentor" drugs
include tryptophan (Tryptan) and buspirone (Buspar).
and sedatives, typically the benzodiazepines, may
be prescribed to ease anxiety and promote sleep. Because
of their high potential for fostering dependence,
these medications are intended only for short-term
or occasional use. Medications often are used not
for their primary function but to exploit what are
normally side effects. Quetiapine fumarate (Seroquel)
is designed primarily to treat schizophrenia and bipolar
disorder, but a frequently reported side-effect is
somnolence. Therefore, this drug can be used in place
of an antianxiety agent such as clonazepam (Klonopin,
such as risperidone (Risperdal), olanzapine (Zyprexa),
and Quetiapine (Seroquel) are prescribed as mood stabilizers
and are also effective in treating anxiety. Their
use as mood stabilizers is a recent phenomenon and
is controversial with some patients. Antipsychotics
(typical or atypical) may also be prescribed in an
attempt to augment an antidepressant, to make antidepressant
blood concentration higher, or to relieve psychotic
or paranoid symptoms often accompanying clinical depression.
However, they may have serious side effects, particularly
at high dosages, which may include blurred vision,
muscle spasms, restlessness, tardive dyskinesia, and
by their nature are stimulants. Antianxiety medications
by their nature are depressants. Close medical supervision
is critical to proper treatment if a patient presents
with both illnesses because the medications tend to
work against each other.
remains the standard treatment for bipolar disorder
and is often used in conjunction with other medications,
depending on whether mania or depression is being
treated. Lithium's potential side effects include
thirst, tremors, light-headedness, and nausea or diarrhea.
Some of the anticonvulsants, such as carbamazepine
(Tegretol), sodium valproate (Epilim), and lamotrigine
(Lamictal), are also used as mood stabilizers, particularly
in bipolar disorder.
to take medication or failure to take it as prescribed
is one of the major causes of relapse. Should one
feel a change or discontinuation of medication is
necessary, it is critical that this be done in consultation
with a doctor.
In psychotherapy, or counseling, one receives assistance
in understanding and resolving habits or problems
that may be contributing to or the cause of the depression.
This may be done individually or with a group and
is conducted by mental health professionals such as
psychiatrists, psychologists, clinical social workers,
or psychiatric nurses.
psychotherapy may result in different habitual thinking
and action which leads to a lower relapse rate than
antidepressant drugs alone. Medication, however, may
yield quicker results and be strongly indicated in
a crisis. Medication and psychotherapy are generally
complementary, and both may be used at the same time.
is important to ask about potential therapists' training
and approach; a very close bond often forms between
practitioner and client, and it is important that
the client feel understood by the clinician. Moreover,
some approaches have been convincingly demonstrated
to be much more effective in treating depression.
can help a person make changes in thinking patterns,
deal with relationship problems, detect and deal with
relapses, and understand the factors that contribute
are many counseling approaches, but all are aimed
at improving one's personal and interpersonal functioning.
Cognitive behaviour therapy has been demonstrated
in carefully controlled studies to be among the foremost
of the recent wave of methods which achieve more rapid
and lasting results than traditional "talk therapy"
analysis. Cognitive therapy, often combined with behavioral
therapy, focuses on how people think about themselves
and their relationships. It helps depressed people
learn to replace negative depressive thoughts with
realistic ones, as well as develop more effective
coping behaviors and skills. Therapy can be used to
help a person develop or improve interpersonal skills
in order to allow him or her to communicate more effectively
and reduce stress. Interpersonal psychotherapy focuses
on the social and interpersonal triggers that cause
their depression. Narrative therapy gives attention
to each person's "dominant story" by means
of therapeutic conversations, which also may involve
exploring unhelpful ideas and how they came to prominence.
Possible social and cultural influences may be explored
if the client deems it helpful. Behavioral therapy
is based on the assumption that behaviors are learned.
This type of therapy attempts to teach people more
healthful types of behaviors. Supportive therapy encourages
people to discuss their problems and provides them
with emotional support. The focus is on sharing information,
ideas, and strategies for coping with daily life.
Family therapy helps people live together more harmoniously
and undo patterns of destructive behavior.
Transcranial magnetic stimulation
Repetitive transcranial magnetic stimulation (rTMS)
is under study as a possible treatment for depression.
Initially designed as a tool for physiological studies
of the brain, this technique shows promise as a means
of alleviating depression. In this therapy, a powerful
magnetic field is used to stimulate the left prefrontal
cortex, an area of the brain that typically shows
abnormal activity in depressed people.
Recent work in Poland suggested that weak, variable
magnetic fields may offer relief from depression in
those who have not responded to medication. However,
some of the existing work has been questioned, with
claims that the effect is not as significant once
environmental conditions are controlled for.
Vagus nerve stimulation
Vagus nerve stimulation therapy is a treatment used
since 1997 to control seizures in epileptic patients
and has recently been approved for treating resistant
cases of treatment-resistant depression (TRD). The
VNS Therapy device is implanted in a patient's chest
with wires that connect it to the vagus nerve, which
it stimulates to reach a region of the brain associated
with moods. The device delivers controlled electrical
currents to the vagus nerve at regular intervals.
Electroconvulsive therapy (ECT), also known as electroshock
or electroshock therapy, uses short bursts of a controlled
current of electricity (typically fixed at 0.9 ampere)
into the brain to induce a brief, artificial seizure
while the patient is under general anesthesia.
has acquired a fearsome reputation, in part from its
use as a tool of repression in the former USSR and
its barbaric fictional depiction in films such as
One Flew Over the Cuckoo's Nest and Requiem for a
Dream, but remains a common treatment where other
means of treatment have failed or where the use of
drugs is unacceptable. Also, in contrast to direct
electroshock of years ago, most countries now allow
ECT to be administered only under anaesthesia. In
a typical regimen of treatment, a patient receives
three treatments per week over three or four weeks.
Repeat sessions may be needed. Short-term memory loss,
disorientation, and headache are very common side
effects. In some cases, permanent memory loss has
occurred, but detailed neuropsychological testing
in clinical studies has not been able to prove permanent
effects on memory. ECT offers the benefit of a very
fast response; however, this response has been shown
not to last unless maintenance electroshock or maintenance
medication is used. Whereas antidepressants usually
take around a month to take effect, the results of
ECT have been shown to be much faster. For this reason,
it is the treatment of choice in emergencies (e.g.,
in catatonic depression in which the patient has ceased
oral intake of fluid or nutrients).
remains much controversy over electroshock. Advocacy
groups and scientific critics, such as Dr Peter Breggin,
call for restrictions on its use or complete abolishment.
Like all forms of psychiatric treatment, electroshock
can be given without a patient's consent, but this
is subject to legal conditions dependent on the jurisdiction.In
Oregon patient consent is necessary by statute.
Other methods of treatment
Bright light (both sunlight and artificial light)
is shown to be effective in seasonal affective disorder,
and sometimes may be effective in other types of depression,
especially atypical depression or depression with
"seasonal phenotype" (overeating, oversleeping,
weight gain, apathy).
note: An antidepressant effect is caused by stimulation
of the retina by the visible light, not by the ultra-violet
portion. Thus, it is not necessary (and may be even
dangerous in some cases) to get sunburn. It can be
enough just to walk at daytime or to take light therapy
using a light box. However, recent discoveries of
the existence and importance of the third kind of
photoreceptor in our eyes, the intrinsically photosensitive
retinal ganglion cells (ipRGC), critical to human
chronobiology, strongly suggest that bluish light
is more helpful, and manufacturers are beginning to
respond to this finding.
It is widely believed that physical activity and exercise
help depressed patients and promote quicker and better
relief from depression. They are also thought to help
antidepressants and psychotherapy work better and
faster. It can be difficult to find the motivation
to exercise if the depression is severe, but sufferers
should be encouraged to take part in some form of
regularly scheduled physical activity. A workout need
not be strenuous; many find walking, for example,
to be of great help. Exercise produces higher levels
of chemicals in the brain, notably dopamine, serotonin,
and norepinephrine. In general this leads to improvements
in mood, which is effective in countering depression.[citation
that before beginning an exercise regime, it is wise
to consult a doctor. He or she can establish whether
a person has any health problems that could contraindicate
some types of exercise.
Meditation is increasingly seen as a useful treatment
for depression. The current professional opinion on
meditation is that it represents at least a complementary
method of treating depression, a view that has been
clearly underscored by the Mayo Clinic. Since the
late 1990s, much research has been carried out to
determine how meditation affects the brain (for more
information see the main article on meditation). Although
the effects on the mind are complex, they are often
quite positive, encouraging a calm, reflective, and
rational state of mind that can be of great help against
depression. Although many religions include meditative
practice, it is not necessary to be a member of any
faith to meditate.
Deep brain stimulation
Though still experimental, a new form of treatment
called deep brain stimulation offers some hope in
the relief of treatment resistant clinical depression.
Published in the journal Neuron (2005), Helen Mayberg
described the implanting of electrodes in a region
of the brain known as Area 25 (Neuron). The electrodes
act in an inhibitory fashion, on an otherwise overactive
region of the brain. Further research is required
before it becomes available as a method of treatment,
but it offers hope for those suffering from treatment
Insulin shock therapy is an old and largely abandoned
treatment of severe depressions, psychoses, catatonic
states, and other mental disorders. It consists of
induction of hypoglycemic coma by intravenous infusion
of insulin. The treatment is potentially unsafe and
can be lethal in some cases (about 1% of patients
undergoing insulin coma), even with proper monitoring.
In contrast, ECT is considered to be very safe.
insulin shock therapy is still officially used in
Russia and some other countries and can be administered
to a very treatment-resistant patient with written
consent in many Western countries.
shock therapy, also known as atropinic coma therapy,
is an old and rarely used method. It consists of induction
of atropinic coma by rapid intravenous infusion of
shock treatment is considered safe, but it entails
prolonged coma (4-5 hours), with careful monitoring
and preparation, and it has many unpleasant side effects,
such as blurred vision. It can be used with written
consent in Western countries in very treatment-resistant
patients and is still officially used in Russia and
some other countries.
Some people with clinical depression may attempt to
dull their feelings of despair by consuming alcohol,
tobacco, or illicit drugs, or using diverse forms
of entertainment. Some people with depression may
resort to cocaine, amphetamines, or opiates for their
mood-altering effects. These attempts at self-medication
may lead to a pattern of alcoholism and drug abuse
that further exacerbates the depression.
Aspartame was associated with a significant difference
in number and severity of symptoms for patients with
a history of depression in an experiment . However,
the main findings of this 1993 study have not been
replicated since, and its methodology has been criticized
on the basis that unrelated symptoms were aggregated
artificially, thereby boosting the statistical difference
between the aspartame and the placebo conditions.
Relapse is more likely if treatment has not resulted
in full remission of symptoms.4 In fact, current guidelines
for antidepressant use recommend 4 to 6 months of
continuing treatment after symptom resolution to prevent
evidence from many randomized controlled trials indicates
that continuing antidepressant medications after recovery
substantially reduces (halves) the chances of relapse.
This preventive effect probably lasts for at least
the first 36 months of use.
evidence suggests that chronic disease is accompanied
by relapses after prolonged treatment with antidepressants
(Tachyphylaxis). Psychiatric texts suggest that physicians
respond to relapses by increasing dosage, complementing
the medication with a different class, or changing
the medication class entirely. The reason for relapse
in these cases is as poorly understood as the change
in brain physiology induced by the medications themselves.
Possible reasons may include aging of the brain or
worsening of the condition. Most SSRI psychiatric
medications were developed for short-term use (a year
or less) but are widely prescribed for indefinite
Social attitudes towards depression
Some employers are reluctant to consider hiring people
with a history of depression, but discrimination on
this basis may be illegal in the United States. U.S.
military standards do not allow more than six months
of treatment for depression before someone becomes
ineligible, though a waiver is possible in some circumstances.[citation
Mental health stigma
Stigmatization and discrimination often stand in the
way of recovery from depression and mental illness.
Many people think that there is something shameful
about being afflicted with mental illness, and this
stigma can lead to discrimination. Such discrimination
may make it more difficult to get an education or
attain worthwhile employment. Stigma also often discourages
people with mental illnesses from getting needed treatment.
may also lead people to assume that those with depression
or bipolar disorder are more likely to be violent
or otherwise dangerous to society, which can lead
to unnecessary fear and avoidance of those with mental
illnesses. This avoidance can be isolating and compound
the effects of depression.
mental illness does not have the visible symptoms
as most non-mental disorders do, treatment has often
been considered less important or deserved than for
physical illness. Many insurance plans do not cover
mental health services to the same degree as other
illnesses. When mental illnesses are covered, coverage
may be limited, inappropriate, or inadequate. Many
jurisdictions are introducing legislation to provide
parity in coverage between mental and non-mental illness.
Black Dog Institute
Body and Spirit