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• What is a Depressive Disorder?
• Types of Depression
• Signs and Symptoms of Depression and Mania
• Causes and Risk Ractors of Depression
• Prognosis
• Depression in Women
• Depression in Men
• Depression in the Elderly
• Depression in Children
• Diagnostic Evaluation and Treatment
• Medications

What is a Depressive Disorder?

A depressive disorder is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.

Types of Depression

Depressive disorders come in different forms. There are several different diagnoses for depression, mostly determined by the intensity of the symptoms, the duration of the symptoms, and the specific cause of the symptoms, if that is known. The most common types of depressive disorders are:

Major Depression - is manifested by a combination of symptoms 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.

Dysthymic Disorder (dysthymia) - A less severe type of depression, which persists for at least two years, and often longer. It involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Symptoms are more enduring and resistant to treatment than in a major depression. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Bipolar Disorder (manic-depressive illness) - 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. If left untreated, mania may worsen to a psychotic state.

Adjustment disorders. If a loved one dies, someone looses a job or receives a diagnosis of cancer, it's perfectly normal to feel tense, sad, overwhelmed or angry. Eventually, most people come to terms with the lasting consequences of life stresses, but some don't. This is what's known as an adjustment disorder — when the response to a stressful event or situation causes signs and symptoms of depression. Some people develop an adjustment disorder in response to a single event. In others, it stems from a combination of stressors. Adjustment disorders can be acute (lasting less than six months) or chronic (lasting longer). Doctors classify adjustment disorders based on the primary signs and symptoms of depression or anxiety.

Seasonal affective disorder. Seasonal affective disorder (SAD) is a pattern of depression related to changes in seasons and a lack of exposure to sunlight. It may cause headaches, irritability and a low energy level.

Signs and 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 time.

Depression symptoms

• Depressed mood. Feeling hopeless, sad, discouraged, anxious or empty. Because of the chronic sadness, excessive sobbing or crying is common.
• Loss of interest or pleasure in hobbies and activities that were once enjoyed. Loss of desire to perform usual activities. Nothing seems to be interest, including former hobbies, social activities, and sex. Person may act more apathetic. Sexual desire may disappear, resulting in lack of sexual activity. Many people become uninterested in life.
• Appetite or weight changes. An increased or reduced appetite. Unexplained weight gain or loss.
• Sleep disturbances. Insomnia, early-morning awakening, or oversleeping (hypersomnia). Waking in the middle of the night or early in the morning and not being able to get back to sleep are typical.
• Psychomotor agitation or retardation. Restlessness, irritability, slow speech and body movements, lack of responsiveness.
• Fatigue or loss of energy. Physically drained, lack of energy. Even small tasks are exhausting. Chronic fatigue, despite spending more time sleeping, is common.
• Low self-esteem. Feelings of guilt, worthlessness, helplessness, poor self-esteem, self-criticism. In the extreme, people may neglect their personal appearance, even neglecting basic hygiene. Depressed people have extremely negative views of themselves
• Impaired ability to think or concentrate. Memory problems; inability to focus; difficulty with concentrating, making decisions; poor attention; indecisiveness.
• Thoughts of death or suicidal ideation. Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide. It has been estimated that between 6% and 15% of people who suffer with severe depression symptoms commit suicide.
• Physical symptoms. Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and musculoskeletal pain.

Mania symptoms

• 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 and Risk Ractors of Depression

There's no single known cause for depression. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Experts believe a combination of factors may trigger an imbalance in brain chemicals called neurotransmitters, resulting in depression. Imbalances in three neurotransmitters — serotonin, norepinephrine and dopamine — seem to be linked to depression.

Scientists don't fully understand how imbalances in neurotransmitters cause signs and symptoms of depression. It's not certain whether changes in neurotransmitters are a cause or a result of depression. Factors that contribute to depression include:

• Chemical imbalances. Altered neurotransmitter (serotonin, norepinephrine, and dopamine) levels are responsible for depression symptoms in many people. Neurotransmitters are chemical substances used by the brain cells to communicate with one another. A serotonin deficit can cause sleep problems, irritability, anxiety (associated with depression), while a norepinephrine deficit can cause fatigue and a low mood. However, it is unclear whether neurotransmitter imbalances trigger the depression or whether the depressive illness itself causes the imbalance. Furthermore, research has shown that not all depressed people have decreased neurotransmitter activity. Some studies have even found increased levels of norepinephrine in depressed patients [1].
• Heredity (genetics). Researchers have identified several genes that may be involved in bipolar disorder, and they're looking for genes linked to other types of depression. 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. 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.
• Gender. Women are about as twice as likely as men to be diagnosed with major depression. The reason for the sex difference in prevalence of depression is not entirely clear. One thought is that men are less likely to actually report the symptoms of depression and when they do, may be more vague in their descriptions, so the discrepancy is mostly due to depression being under-diagnosed in men. Another factor may be that men "mask" or hide their depression behind other problems, such as alcohol and drug abuse. Another possible reasons may be that various social and mental factors predispose women to depression and related mental health disorders. Also, being a woman increases the risk for depression through hormonal factors related to the reproductive cycle.
• Stress. Stressful life events, particularly difficult relationship, loss or threatened loss of a loved one, can trigger depression. Work problems, including job loss and unemployment, can trigger depression as well. In fact, stress is a major factor in depression relapse following recovery.
• Early life trauma. Indeed, exposure to extraordinary life stressors early in life, such as loss of parents or sexual or physical abuse has been well documented to increase the risk for depression and suicide.
• Medications. Long-term use of certain medications, such as some drugs used to control high blood pressure, tranquilizers, sedatives, antihistamines, muscle relaxants, appetite suppressants, sleeping pills or, occasionally, birth control pills, may cause symptoms of depression in some people.
• Illnesses. Having a chronic illness, such as heart disease, stroke, diabetes, cancer, Parkinson's disease, hormonal disorders or Alzheimer's disease, puts you at higher risk of developing depression. Having an underactive thyroid (hypothyroidism), even mildly, also can cause depression.
• Personality. Certain personality traits, such as having low self-esteem and being overly dependent, self-critical, pessimistic and easily overwhelmed by stress, can make you more vulnerable to depression.
• Postpartum depression. It's common for mothers to feel a mild form of distress that usually occurs a few days to weeks after giving birth. During this time they may have feelings of sadness, anger, anxiety, irritability and incompetence. A more severe form of the baby blues, called postpartum depression, also can affect new mothers.
• Hormones. Women experience depression about twice as much as men, which leads researchers to believe hormonal factors may play a role in the development of depression.
• Substance abuse. Experts once thought that people with depression used alcohol, nicotine and mood-altering drugs as a way to ease depression. But using these substances may actually contribute to depression and anxiety disorders.
• Nutritional deficiencies. In fact, certain vitamin, mineral, and amino acid deficiencies can cause symptoms of depression. Depression can be aggravated by deficiencies of omega-3 fatty acids, folic acid, vitamin B, vitamin C, calcium, copper, iron, magnesium, potassium, or biotin.
• Social factors. As for most mental disorders, rates of depression increase with decreasing socioeconomic status. Some studies suggest that Western cultural attitudes that link income to social status may play a significant role in the connection between poverty and depression.

Prognosis

Untreated episodes of clinical depression typically last from 6 to 24 months. With proper treatment, about two-thirds of people will recover and be able to return to their normal activities. About 25% of all people will continue to exhibit moderate to severe symptoms for months to years after the initial episode. Nearly 10% of people with depression will have continued or intermittent symptoms for 2 or more years.

Depression in Women

Women experience depression about twice as often as men. This two-to-one ratio exists regardless of racial and ethnic background or economic status. The same ratio has been reported in eleven other countries all over the world. Men and women have about the same rate of bipolar disorder (manic depression), though its course in women typically has more depressive and fewer manic episodes. Also, a greater number of women have the rapid cycling form of bipolar disorder, which may be more resistant to standard treatments.

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 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 hormonal manipulation.

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, 6 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 85.

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

Growing old certainly involves a variety of life stressors that can lead to depression. Some people have trouble making the transition from full time productive careers to retirement. Others have been forced to retire because of chronic health problems or disability. The loss of a loved one, or serious illness in a lifelong friend, or in a spouse, can add tremendous caretaking responsibilities, and also creates much sadness. Lack of mobility, either due to physical illness, or loss of driving privileges, can result in social isolation and loneliness. All these factors can lead to depression.

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.

It is important to identify and treat the underlying depression. Healthcare professionals should recognize what symptoms may be side effects of medication the older person is taking for a physical problem, or what 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.

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 or a teacher become worried about how the child's behavior has changed. 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.

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 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 doctor is usually able to diagnose depression from its signs and 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. A previous history of depression or a family history of depression helps to confirm the diagnosis. Excessive worrying, panic attacks, and obsession are common in depression and may lead the doctor to incorrectly think that the person has an anxiety disorder.

In older people, depression may be difficult to notice, especially among people who do not work or who have little social interaction. Depression may lead to slower thinking, decreased concentration, and memory impairment that simulates dementia.

Standardized questionnaires are used to help measure the degree of depression. Two such questionnaires are the Hamilton Depression Rating Scale, conducted verbally by an interviewer, and the Beck Depression Inventory, a self-administered questionnaire.

An untreated depression may last for about 6 months. Although mild symptoms persist in many people, functioning tends to treturn to normal. Nonetheless, most people with depression experience repeated episodes of depression, an average of 4 to 5 times over a lifetime.

Treatment choice will depend on the outcome of the evaluation. Depression today is usually treated without hospitalization. However, sometimes a person should be hospitalized, especially if he is contemplating suicide or has attempted it, is too frail because of weight loss, or is at risk of heart problems because of severe agitation.

The development of newer antidepressant medications and mood-stabilizing drugs has improved the treatment of depression. Medications can relieve symptoms of depression and have become the first line of treatment for most types of the disorder. Other treatments include psychotherapy and electroconvulsive therapy. 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 required.

Medications

Antidepressants do not cure depression, they act by controlling symptoms. Like most drugs used in medicine, antidepressants correct or compensate for some malfunction in the body. In many cases, these medications can help a person get on with life despite some continuing mental pain and difficulty coping with problems.

Doctors usually treat depression in two stages. Acute treatment with medications helps to relieve symptoms until patient feels well. Once the symptoms ease, maintenance treatment typically continues for four to nine months to prevent a relapse. Episodes of depression recur in the majority of people who have one episode, but continuing treatment greatly reduces the risk of a rapid relapse.

There are several types of antidepressant medications used to treat depressive disorders.

Selective serotonin reuptake inhibitors (SSRIs). SSRIs are now the most commonly used class of antidepressants. They seem to work by increasing the availability of the neurotransmitter serotonin in the brain. SSRIs are effective in treating depression and dysthymia as well as other mental health disorders that often coexist with depression. Although SSRIs can cause nausea, diarrhea, tremor, weight loss, and headache, these side effects are usually mild or go away with continued use. Most people tolerate the side effects of SSRIs better than the side effects of tricyclic antidepressants. SSRIs are safer than the tricyclics in their side effects on the heart. However, with long term use, SSRIs may cause additional side effects, such as weight gain. Abrupt discontinuation of some of the SSRIs may result in a withdrawal syndrome that includes dizziness, anxiety, irritability, and flu-like symptoms.

Because of the potentially serious interaction between these medications and monoamine oxidase inhibitors, it is advisable to stop taking one medication from 2 to 4 or 5 weeks before starting the other, depending on the specific medications involved. In addition, some SSRIs have been found to affect metabolism of certain other medications in the liver, creating possible drug interactions.

Drugs similar to SSRIs include serotonin and norepinephrine reuptake inhibitors (SNRIs), such as trazodone (Desyrel) and venlafaxine (Effexor), and dopamine reuptake inhibitors, such as bupropion (Wellbutrin).

Tricyclic and tetracyclic antidepressants. These medications also affect neurotransmitters, but by a different mechanism than SSRIs. They may be used for any type of depression, be it mild or severe, though, they are now used infrequently. Among tricyclic antidepressants are amitriptyline, desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), trimipramine (Surmontil) and a combination of perphenazine and amitriptyline. Tetracyclics include maprotiline and mirtazapine (Remeron). Tricyclics often cause sedation and lead to weight gain. They can also cause an increase in heart rate and a decrease in blood pressure when the person stands. Other side effects include blurred vision, dry mouth, confusion, constipation, and difficulty in starting to urinate. These other side effects are called anticholinergic effects and are often more pronounced in older people.

Monoamine oxidase inhibitors (MAOIs). These drugs, which include phenelzine (Nardil) and tranylcypromine (Parnate), prevent the breakdown of neurotransmitters. The drugs have potentially serious side effects if combined with certain other medications or food products. Doctors rarely use them unless other options have failed. People who use MAOIs must adhere to a number of dietary restrictions and follow special precautions. For example, they should not eat foods or beverages that contain tyramine, such as beer on tap, red wines, liqueurs, overripe foods, salami, aged cheeses, fava or broad beans, yeast extracts, and soy sauce. They must avoid pseudoephedrine, found in many over-the-counter cough and cold remedies. This drug, when combined with MAIOs, can cause sudden and severe rise in blood pressure with severe, throbbing headache. People who take MAOIs should also avoid many other types of drugs, including tricyclic antidepressants, SSRIs, bupropion, mitrazapine, venlafaxine, nefazodone, dextromethoephan, and meperidine.

Psychostimulants. Doctor may initially prescribe a stimulant such as methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine, Dextrostat) or modafinil (Provigil) if patient can't take antidepressants because they are contraindicated due to another medical condition. These medications are also sometimes given in conjunction with antidepressants.

Lithium and mood-stabilizing medications. Doctors prescribe lithium (Eskalith, Lithobid), valproic acid (Depakene), divalproex (Depakote) and carbamazepine (Tegretol, Carbatrol) to treat bipolar depression. Medications called atypical antipsychotics such as olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel) were initially developed for treatment of psychotic disorders. Doctors sometimes also use them to treat bipolar disorder.

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.

Notes:

• 1. Steve Tokar. Patients with depression skip medications and have elevated levels of norepinephrine. MedicalNewsToday

More information about Depression:

• Alternative Therapies for Depression
• Natural Treatments for Depression