Depression

Overview

What Is It?

If you are depressed, you feel a sense of helplessness, hopelessness or despair. You lose interest in your favorite activities, may experience changes in appetite, weight and sleep patterns, have difficulty concentrating and may be preoccupied with death or suicide.

Feelings of sadness can be normal, appropriate and even necessary during life's setbacks or losses. Or you may feel blue or unhappy for short periods without reason or warning, which also is normal and ordinary. But if such feelings persist or impair your daily life, you may have a depressive disorder. Severity, duration and the presence of other symptoms are factors that distinguish ordinary sadness from a depressive disorder.

Depression can happen to anyone of any age, race, class or gender. According to Mental Health America, depression afflicts more than 21 million Americans each year, 12 million of whom are women. Women are twice as likely as men to suffer from depression. Many women first experience symptoms of depression during their 20s and 30s. Once you experience depression, there's a 50 percent chance you'll be depressed again. Once you've experienced two episodes, you have a 70 percent chance of being depressed again. And once you've experienced three episodes, you have a 90 percent chance of being depressed again.

A complex combination of physiological, social, environmental, cultural, hormonal, biological and psychological factors may contribute to the reasons why women experience depression at a higher rate than men.

Depression affects both mind and body. If you are depressed, you feel a sense of helplessness, hopelessness or despair. You lose interest in your favorite activities; may experience changes in appetite, weight and sleep patterns; have difficulty concentrating; and may be preoccupied with death or suicide.

Additionally, depression often occurs in conjunction with certain chronic illnesses, like diabetes, and after a heart attack or stroke. Research suggests that depression is a risk factor for the development of coronary artery disease and may even be a major risk factor for osteoporosis. It also can develop as a result of conditions that cause unrelieved pain. Left untreated, depression contributes to increased complications, prolonged recovery time and a greater chance of death.

The good news is that depression is a treatable illness. Yet, 10 to 30 percent of people treated for a major depressive episode will have an incomplete recovery, with persistent symptoms of depression or dysthymia.

One reason that treatment for depression is inadequate is that many people do not know or are confused about where to seek mental health treatment. Another reason is that many individuals do not perceive depression as a real medical condition that should or could be treated. Also, there is still a social stigma attached to mental illnesses like depression. These perceptions are wrong. Depression is a potentially life-threatening disorder, and anyone suffering from its debilitating symptoms deserves to have it treated.

Types of Depression

Depression is classified as a mood disorder. The primary types of depression are:

Major depression: Major depression is marked by a combination of symptoms that interfere with life activities, such as work, sleep and eating, as well as a loss of interest in previously pleasurable activities. The depressed mood represents a change from previous behavior or mood and has lasted for at least two consecutive weeks.

Dysthymia: This is a form of chronic but low-grade depression marked by low energy, a general negativity and a sense of dissatisfaction and hopelessness. A person suffering from dysthymia may experience many of the same symptoms that occur in major depression, but they are less intense and last much longer—at least two years. If you suffer from dysthymia, you may not feel good, but you aren't as disabled as during an episode of major depression. However, sometimes women with dysthymia also suffer from episodes of major depression, a condition known as double depression.

Postpartum depression (PPD): While the "baby blues" are common in many women within the first few days or weeks following pregnancy and childbirth, they are temporary. However, for some women these symptoms become more severe and long-lasting. This is known as postpartum depression. The condition typically occurs within a month after the baby is born. About 10 to 15 percent of women report diagnosable postpartum depression after giving birth. If you've had prior depressive episodes, you have a much higher risk of developing postpartum depression. Postpartum depression can seriously interfere with your ability to care for yourself and your child. You should report any symptoms immediately to your health care professional for further evaluation.

Premenstrual dysphoric disorder (PMDD): The syndrome of more severe depression, irritability and tension occurring seven to 14 days prior to the start of the menstrual period is known as premenstrual dysphoric disorder (PMDD), also called late-luteal phase dysphoric disorder. It affects 3 to 8 percent of women of childbearing age. Though PMDD shares many of the characteristics of premenstrual syndrome (PMS), particularly the timing of the symptoms, there are differences between the two. When diagnosing PMDD, the focus is more on the mood-related symptoms than physical symptoms because the mood-related symptoms are significantly more severe in PMDD than in PMS. Experts say the difference between PMDD and PMS is similar to the difference between a mild tension headache and a migraine.

Seasonal affective disorder (SAD): Also called winter depression, SAD is a form of depression that affects an estimated 10 to 20 percent of Americans when both its mild and severe forms are considered. Women are more likely than men to suffer from SAD. The key feature of SAD is your response to less light during the winter months. Experts believe that brain chemistry in some people is affected by diminished daylight, triggering depression at this time of the year. However, it is episodic—it comes and goes—and many people who experience SAD recover in the spring. These people, however, have an increased risk of developing bipolar disorder, another form of depression.

Bipolar disorder: This form of depression is sometimes called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by intense episodes of elation and despair, with any combination of mood experiences in between, including periods of normal moods. When in the depressed phase, an individual can have any or all of the symptoms of a depressive disorder. Symptoms during the manic phase include a decreased need for sleep, increased talkativeness, racing thoughts and increased activity, including sexual activity, excessive spending or having a great deal of energy. Sometimes manic episodes may include extreme irritability. Women who are bipolar may have more episodes of depression than mania.

Diagnosis

Researchers are unclear about the specific causes of depression. An imbalance of certain chemicals in the brain called neurotransmitters, including serotonin, dopamine and norepinephrine, may be partly responsible. Low levels of folate may also contribute. Also, some people may have a genetic predisposition to depression; that means your family history puts you at risk.

If you have a history of substance abuse, or physical or sexual abuse, you are particularly at risk for depression. Also, women who are separated or divorced, living in poverty or married with young children at home are more vulnerable to depression than other women.

Because depression is so common, your primary health care professional should ask you about any symptoms of depression you may be experiencing during any comprehensive physical examination. Keep in mind that although primary care physicians are qualified to treat depression, they may not be the best choice of provider in all cases, particularly if the depression is severe. And women themselves may be unable to sense or admit to their own depression.

If your primary health care professional suspects a depressive disorder, he or she may request a consultation with a mental health specialist such as a psychiatrist, clinical social worker or clinical psychologist. To assess your mental health, a health care professional may ask you questions like:

• Have you been sad a lot lately?
• Have you had crying spells?
• Is there a change in your productivity or your ability to concentrate?
• How does your future look?
• Do you have difficulty making decisions?
• Have you lost interest in aspects of life that used to be important to you?
• Are you tired?
• Do you feel guilty or like a failure?
• Do you ever wish you were dead?

Untreated episodes of major or acute depression last an average of about six months. At least five of the symptoms below must occur for a period of at least two consecutive weeks, and they must represent a change from previous behavior or mood, to receive a diagnosis of major or acute depression.

• depressed mood on most days for most of each day
• total or very noticeable loss of pleasure most of the time
• significant increase or decrease in appetite, weight or both
• sleep disorders, either insomnia or excessive sleepiness, nearly every day
• loss of energy and a daily sense of tiredness
• sense of guilt and worthlessness nearly all the time
• change in psychomotor activity
• inability to concentrate occurring nearly every day
• recurrent thoughts of death or suicide

How to Tell the Difference Between Depression and Other Mood-Related Conditions

The symptoms of grief or bereavement mimic those of depression in many ways, but if you are grieving, you experience a succession of emotions over a period of three to six months that lead to a recovery period. Severe grief lasting longer than six months affects your health and increases your risk for ongoing depression, however. Some experts suggest that this severe persistent grieving state be categorized as a separate psychological diagnosis termed complicated grief disorder, which would be related to post-traumatic stress syndrome and require special treatment.

Dysthymia (chronic, low-grade depression) is marked by the same symptoms as major depression but is not usually accompanied by changes in appetite or sexual drive, and severe agitation, sedentary behavior and suicidal thoughts are not usually present. Possibly because of the duration of the symptoms, you may not exhibit marked changes in mood or daily functioning. However, treatment for dysthymia is important because it is effective and prevents a lifetime of sadness.

As the days get shorter, people with seasonal affective disorder (SAD) get increasingly tired and lethargic and have difficulty concentrating. You may also experience a craving for carbohydrates and sweets. Your appetite increases, often resulting in weight gain, and as the winter darkens you may become socially withdrawn and despondent. The exact causes of SAD are unclear. One theory is that serotonin, a chemical in the brain widely believed to play a major role in depression, is triggered by sunlight and falls to its lowest level during the winter months. If you are affected by SAD, you may have less serotonin available or be less able to handle the decrease than those unaffected by the disorder.

Like other forms of depression, the causes of postpartum depression have not been pinpointed, but both psychologic and neurochemical influences are suspected. Women who experience postpartum depression very often have had problems with depression prior to pregnancy. Also, if you experience premenstrual syndrome (PMS), you may be more susceptible to varying degrees of postpartum depression. Another significant risk factor is lack of social support for the mother and baby. The stress involved with adjustment to a new baby; being unprepared and subsequently overwhelmed by the baby's birth; a difficult birthing experience; a sick or colicky infant; and exhaustion may also contribute. Symptoms of postpartum depression include:

• uncontrollable crying
• feelings of inadequacy or negative feelings toward the baby
• irritability
• anxiety or panic
• feeling numb
• excessive sleep or inability to sleep
• over- or under-eating
• other symptoms common to depression

The most severe form of postpartum depression can include intense, suicidal and homicidal thoughts and/or postpartum psychosis. Only about one woman in 1,000 experiences this serious form of postpartum depression following childbirth.

The symptoms of premenstrual dysphoric disorder (PMDD) are similar to those of major depressive disorder but subside with the onset of menstruation. They include: a markedly depressed mood, decreased interest in usual activities, lethargy, fatigue or lack of energy, insomnia and hypersomnia (sleeping too much). A diagnosis of PMDD requires that these symptoms occur during most menstrual cycles, get worse seven to 14 days before the menstrual period begins and improve once it starts or soon afterward.

Treatment

If you aren't sure whether to seek help for a mood disorder or emotional problem, ask yourself, "Could I use some help right now?" The questions below may help you decide:

• Is the problem interfering with your work, relationships, health or medical conditions or other aspects of your personal life?
• Have you been feeling less happy, less confident and less in control than usual for a period of several weeks or longer?
• Have close, trusted friends or family members commented on changes in your behavior and personality?
• Have your own efforts to deal with a problem failed to change your behavior or improve the situation?
• Is dealing with everyday problems more of a struggle than before?
• Are you having suicidal thoughts?

If you answered yes to any of these questions, talk to your health care professional about how you are feeling.

Left untreated, depression can be devastating—an estimated 1 percent of women and 7 percent of men with a lifetime history of depression will eventually commit suicide. What's more, depression is known to play a major role in exacerbating existing medical conditions and may even predispose people to develop other illnesses. Depression may have adverse effects on the immune system, blood clotting, blood pressure, blood vessels and heart rhythms.

Unfortunately, many people who suffer from depression do not seek help. They believe that nothing can help, or that they can simply cure themselves. Many women and their families don't understand that depression is a medical illness. Many mothers struggling with postpartum depression don't seek help because they feel guilty, believing that they shouldn't be sad now that they have a baby. Furthermore, because some symptoms of depression are common to other medical illnesses, depression is often misdiagnosed. The tragedy of this is that in the last few decades, treatments have emerged that can lead to recovery for most sufferers.

With accurate diagnosis and proper treatment, you can learn how depression affects your life and get the help you need to be productive again. In fact, 80 percent of individuals who are depressed recover with appropriate treatment.

Reaching out for help is a wise step when you can't spring back from sad or depressed moods or when emotional difficulties begin to interfere with work, relationships or other aspects of your life. But it's often difficult to seek help because depression typically robs your motivation and energy.

The single most important function your health care professional can perform is to distinguish between mild and severe depression. If your depression is mild, you may need an antidepressant and/or a referral to a clinical psychologist or social worker for counseling. If your depression is severe, however, you may need to see a specialist such as a psychiatrist, who can determine the treatment. Although primary care physicians are qualified to treat depression, they may not be the best choice of provider in severe cases. No matter what type of health care professional you are seeing for your depression, it's important that you communicate honestly about your illness, your current treatment and other treatment options. Though it can be challenging, you can find another medical professional if you are not satisfied with the care you're receiving.

Psychotherapy

Most cases of major depression can be successfully treated with psychotherapy, medication (known as antidepressants) or both. Depression often improves within a few months of starting psychotherapy.

Psychotherapy focuses on changing negative thinking and behaviors and/or unhealthy relationships that can contribute to depression. Talking to a psychological counselor can provide relief, lead to new insights and help replace unhealthy behaviors with more effective ways of coping with problems. Most mental health professionals tailor their approach to the needs, problems and personality of the person seeking help, and they may combine different techniques. The various types of psychotherapy include:

• Cognitive-behavioral therapy, which focuses on identifying distorted perceptions you may have of the world and yourself, changing these perceptions and discovering new patterns of actions and behavior.
• Behavior therapy, which is based on the premise that if you are depressed, you behave in ways that reduce positive outcomes and increase negative consequences. Behavioral activation therapists help you change what you do so you can change how you feel. You create a list of enjoyable or rewarding activities and begin with the easiest and continue in an organized fashion. For instance, you might be encouraged to become more active or add pleasurable activities to your life, learn to assert yourself, or create relaxation techniques.
• Interpersonal therapy (IPT) acknowledges the childhood roots of depression but focuses on symptoms and current issues that may be causing problems. IPT does not delve into the psychological origins of symptoms; rather, it concentrates on relationships as the key to understanding and overcoming emotional difficulties. The therapist seeks to redirect the patient's attention, which has been distorted by depression, outward toward the daily details of social and family interaction. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (three to four months of weekly appointments). Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes and isolation. People with major depression, chronic difficulties developing relationships, dysthymia or the eating disorder bulimia are most likely to benefit.

Cognitive-behavioral therapy and interpersonal therapy have been shown in clinical trials to work as well as antidepressant drugs for treating mild cases of depression, although they take longer than medication to achieve results.

Other therapies are available, but most haven't been proven effective in treating depression. These include:

• Psychodynamic psychotherapy, which concentrates on working through unresolved conflicts from childhood. Some psychiatric specialists view depression as a grieving process for the loss of a parent or other significant person, or for the loss of their love. Others theorize that depressed individuals can only express rage at this loss by turning it against themselves and transforming it into depression. Psychodynamic therapists discuss their patients' early experiences and repressed feelings to provide insight into current problems and bring about behavioral change. Therapy may be brief or may continue for several years.
• Supportive psychotherapy is meant to provide the patient with a nonjudgmental environment by offering advice, attention and sympathy. The goal of supportive psychotherapy, which can be brief or long-term, is to help patients who may temporarily feel unable to cope during times of great stress, such as after learning that they have a serious physical illness. Although many people think of supportive psychotherapy as simply giving comfort and advice, the process is far more complex and may include therapeutic techniques such as education, reassurance, reinforcement, setting limits, social skills training and medication. Supportive therapy appears to be particularly helpful for improving compliance with medications by giving reassurance, especially when setbacks and frustration occur.

Medications

If you have major or chronic depression, you may be prescribed an antidepressant.

Antidepressants are thought to alter the action and distribution of brain chemicals and can be effective in bringing mood, appetite, energy level, outlook and sleep patterns back to normal. About 80 percent of people with major depression will improve with good compliance and adequate doses of the right antidepressant drug.

To reduce or avoid side effects, you may be started on low doses that increase over time. You and your health care professional should first thoroughly discuss your medical history, including the presence of any emotional disorders in family members, and assess your overall health to rule out any illnesses that might be causing your psychiatric symptoms. You should also weigh the benefits and risks of the medication with input from your health care professional. While current antidepressants are not addictive, virtually all have side effects and sometimes serious interactions with other drugs. You should inform your health care professional of any drugs you take, including over-the-counter medications and herbal remedies.

If you have never been treated for depression, your medications will probably be maintained for six months or longer after your depression improves. Some women, however, may require a longer time or even indefinite maintenance therapy. Note: According to the U.S. Food and Drug Administration (FDA), there is an increased suicide risk associated with antidepressants. If you begin to feel like hurting yourself or killing yourself, or someone close to you notices a drastic change in your behavior, be sure to get in touch with your health care provider or call a suicide hotline for help and guidance right away.

Medications used to treat depression include:

Selective serotonin reuptake inhibitors (SSRIs) are now usually the first-line treatment of major depression. They are thought to work by blocking a pump mechanism in the brain that normally moves serotonin back into brain cells. Blocking this action temporarily increases the level of serotonin outside brain cells, especially in the specialized connection zones (synapses) between the brain cells. Because they act on serotonin specifically, SSRIs have fewer side effects than tricyclic antidepressants, which affect a number of chemicals in the body. Commonly prescribed SSRIs include fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram oxalate (Lexapro).

People taking SSRIs report not only relief of depressive symptoms, but also a higher level of efficiency, energy and better relationships.

Some people may notice an improvement of their symptoms within two weeks of taking an SSRI; in others, it can take up to eight weeks. If you don't respond to your medication after eight weeks, tell your health care professional. He or she may adjust the dosage or try another SSRI. Escitalopram oxalate (Lexapro), the newest antidepressant in its class, appears to offer some advantages over some other SSRIs in the treatment of depression: higher potency and lower incidence of side effects. Additionally, the drug is approved for the treatment of generalized anxiety disorder.

The most common side effects of SSRIs are nausea and gastrointestinal problems. Other possible side effects include anxiety, drowsiness, sweating, headache, difficulty sleeping and mild tremor. All usually wear off over time. During the first few weeks of treatment, some people lose a small amount of weight but, in general, they regain it. Sexual dysfunction, including delay or loss of orgasm and low sexual drive, occurs in up to 50 percent or more of people and is a major reason people quit taking their medicine. However, these side effects can usually be managed or reduced with a different medication or by prescribing an additional medication.

More rarely, SSRIs may cause bruising or bleeding in those who are predisposed to bleeding, such as the elderly. SSRIs can also cause dry mouth, which increases the risk of oral health problems. You can increase salivation by chewing sugarless gum, using saliva substitutes and frequently rinsing your mouth.

Some people taking SSRIs report a group of side effects known as extrapyramidal symptoms, which are similar to those in Parkinson's disease and affect the nerves and muscles controlling movement and coordination. They are very uncommon, however. If they develop, it tends to be in the first month of treatment.

Contact your health care professional if you experience any bothersome side effects. Don't discontinue your medication without guidance from a health care professional who is familiar with your health history.

Also, if you are taking an SSRI and are pregnant or plan to become pregnant, discuss potential risks with your health care professional as soon as possible. To date, studies on the risks of SSRIs during pregnancy have had mixed results, in part depending on the specific medication.

• Serotonin-norepinephrine reuptake inhibitors (SNRIs). This class of antidepressants works on two neurotransmitters in the brain important in mood—norepinephrine and serotonin. The drugs in this class approved for the treatment of depression are venlafaxine (Effexor) and duloxetine (Cymbalta). These drugs tend to have fewer adverse effects on sexual function than SSRIs, and some people even report enhanced sexuality. Common side effects include drowsiness, nausea, dizziness and dry mouth.
• Tricyclic antidepressants had been the standard treatment for depression before the introduction of SSRIs. Some of the most frequently prescribed tricyclics are amitriptyline (Elavil), desipramine (Norpramin), clomipramine (Anafranil), doxepin (Sinequan), imipramine, (Tofranil), nortriptyline (Pamelor, Aventyl), protriptyline (Vivactil) and trimipramine (Surmontil). Tricyclics are as effective as SSRIs and may offer benefits for many people with chronic depression who do not respond to SSRIs or other antidepressants. They are much less expensive than SSRIs and SNRIs but cause more potentially severe side effects than those newer antidepressants.
  
  Tricyclic antidepressants may also be used to treat chronic pain-related symptoms, even when a person is not depressed. These medications help restore the body's normal perception of pain.
  
  Side effects are fairly common with these medications and include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty urinating, constipation, disturbances in heart rhythm, drowsiness and dizziness. Blood pressure may drop suddenly when sitting up or standing. Tricyclics can also have serious, although rare, side effects and can cause fatal overdose.
• Monoamine oxidase inhibitors (MAOIs) are usually indicated when other antidepressants don't work. They include phenelzine (Nardil), isocarboxazid (Marplan) and tranylcypromine (Parnate).
  
  There is also an antidepressant patch, selegiline (Emsam), that delivers the MAO inhibitor selegiline into the bloodstream through the skin. In its lowest strength, Emsam can be used without the dietary restrictions (described below) that are needed for all oral MAOIs approved for treating major depression.
  
  MAOIs take up to six weeks to become effective. They commonly cause a sudden drop in blood pressure upon standing that can make you dizzy, drowsiness, sexual dysfunction and insomnia. An extremely serious adverse effect is severe hypertension that could lead to stroke brought on by eating certain foods that have high levels of the amino acid tyramine, such as aged cheese, red wine, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans and concentrated yeast products. This class of drugs also can cause birth defects and should not be taken by pregnant women. They may also interact with other drugs, including common over-the-counter cough medications, stimulants such as Ritalin and decongestants. Very dangerous side effects can occur from interactions with other antidepressants, including SSRIs. You should take at least a two- to five-week break between taking an MAOI and any other form of antidepressant.
• Aminoketone antidepressants: bupropion (Wellbutrin, Wellbutrin SR, Zyban) appears to work by blocking dopamine uptake. The side effects of are similar to those of other antidepressants. Bupropion does not, however, have the degree of sexual side effects common with other antidepressants. People with a seizure disorder or at risk of a seizure disorder should not use bupropion.

Some people experience withdrawal symptoms when stopping an antidepressant. Therefore, when discontinuing an antidepressant, you should gradually withdraw under your health care professional's supervision.

Other treatment options

Other treatments for depression include:

• Estrogen therapy. This menopausal hormone therapy is sometimes used with other treatments to relieve mood-related symptoms such as irritability, mood swings and depression, particularly during the transition to menopause. Some women become depressed because of sleep deprivation caused by night sweats. In this situation, estrogen may be prescribed to reduce night sweats and improve sleep which may, in turn, improve depression. Estrogen therapy also has some benefits when used to relieve depression in elderly women who don't respond to standard antidepressants and to relieve symptoms of postpartum depression.
  
  However, the U.S. Food and Drug Administration now recommends that health care professionals prescribe the lowest dose and the shortest treatment duration for all hormone therapies that contain estrogen. Studies generally find that estrogen's antidepressant affect is relatively mild, and that it primarily works on mild depression mood-related symptoms or in combination with an antidepressant.
• St. John's wort (Hypericum perforatum) is an herbal remedy that may help relieve mild to moderate acute depression in some people. It is widely prescribed in Germany, and European studies show that St. John's wort is more effective than a placebo and as effective as some anti-depressants in the short-term treatment of depression. However, studies find little to no effect in treating major depression.
  
  Hypericin, the active substance in St. John's wort, is manufactured in tablet and liquid form. However, this herbal substance is not regulated and there is no guarantee of quality or purity in any brands currently available. Effective dose levels have not been established.
  
  Common side effects of St. John's wort include gastrointestinal problems, dry mouth, allergic reactions and fatigue. It may also increase sensitivity to the sun, and some people have reported temporary nerve damage after sun exposure. People with severe depression, pregnant or nursing women and children should not take St. John's wort. It should never be combined with other antidepressants. Because this herbal substance may be similar to MAOI inhibitors, some experts suggest avoiding foods and substances that have high amounts of tyramine, such as red wine, dried meat and aged cheese.
• Augmentation strategies generally involve drugs not typically thought of as antidepressants in combination with an antidepressant. Such strategies are being used for people who do not respond to standard therapies or to speed up the response to the antidepressant. Augmentation therapies include lithium, stimulants such as Ritalin, thyroid hormones and anti-anxiety drugs. Additionally, estrogen is sometimes used to augment antidepressant therapy in postmenopausal women. Bupropion and buspirone have also been used. Anti-anxiety drugs, stimulants or sedatives are not antidepressants, however, and they are not effective when taken alone for a depressive disorder.

You should start feeling better within about four to 10 weeks of starting drug therapy. If you do not experience any relief within that time, talk to your health care professional or therapist or seek a second opinion. A change in your therapy approach, medication or dosage may make a significant difference. Psychiatrists with an expertise in drug therapy can usually find a medication that works even if it means switching drugs several times.

Sometimes a physician may write a prescription but not follow up to see if it's working or if the dosage is correct. You should continue to communicate with your health care professional so that an effective, tolerable dosage can be established.

While your health care professional will most likely begin treatment with psychotherapy and/or antidepressants or other medications, there are other treatments for depression, including:

• Electroconvulsive therapy (ECT). Commonly called shock treatment, ECT has been used for more than 70 years and has been refined since its early introduction as a treatment for depression. According to Mental Health America, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals.
  
  Once considered a controversial procedure, ECT has been refined over the years and now successfully works in the majority of mood-disorder people who undergo this treatment. (However, some studies show that the relapse rate is high.) It is recommended for people with severe depression who do not respond to medication. ECT may also be considered when certain medical conditions, such as pregnancy, make the use of medication too risky.
  
  Before receiving ECT, you get a muscle relaxant and short-acting anesthetic. Then a small amount of current is sent to your brain, causing a generalized seizure that lasts for about 30 to 90 seconds. You won't remember the treatments and will probably awake slightly confused. You will most likely recover in five to 15 minutes and be able to go home the same day. Acute treatments usually occur three times per week for about a month.
  
  Although ECT has been performed for decades, researchers still don't know precisely how it works to combat depression, but they know it does work. Most people receive treatments three times a week for a total of six to 12 treatments. Others may require maintenance ECT, which usually involves treatments once a week, gradually decreasing to monthly treatments.
  
  Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness and heart disturbances. ECT may be beneficial for people who cannot take antidepressant drugs, for suicidal people and for elderly people who are psychotic and depressed. Some health care professionals feel it is safer to use ECT than many antidepressants for pregnant women or for people who have certain heart problems. Some psychiatrists believe that it may also be helpful for adolescents who fit the adult criteria for ECT.
  
  Although myths and negative perceptions continue to be perpetuated about ECT, it is a very effective treatment for many people with severe depression who don't respond to other treatments. Researchers are developing better ways to provide this treatment with fewer side effects.
• Exercise may reduce mild to moderate depression. Either brief periods of intense training or prolonged aerobic workouts can raise feel-good chemicals in the brain like endorphins, adrenaline, serotonin and dopamine, which produce the so-called runner's high. It also appears to elevate the body's levels of phenylethylamine, a natural chemical linked to energy, mood and attention. Meanwhile, physical activity, particularly rhythmic aerobic and yoga exercises, helps combat stress and anxiety. And, of course, weight loss and increased muscle tone can boost self-esteem.
• Phototherapy is recommended as the first-line treatment for seasonal affective disorder (SAD). You sit a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) 10 to 20 times brighter than ordinary indoor light for 30 minutes or more every morning. Studies show that phototherapy leads to a reduction in depressive symptoms in most people; however, phototherapy has not been proven to be effective in the prevention of SAD or the treatment of the disorder long-term. Some people report mood improvement as early as two days after treatment; in others, depression may not lift for two to four weeks. If no improvement is experienced after that, then the depression is probably caused by factors other than lack of sunlight. Side effects include headache, eye strain and irritability, although these symptoms are usually minimal and tend to disappear within a week. Severe SAD may require both phototherapy and antidepressant medications. Stress management and exercise can also help relieve symptoms of seasonal affective disorder.
• Support. Support is particularly important for anyone seeking treatment and relief from depression. Typically, support comes from family members but can also be provided by friends, relatives, coworkers or members of a faith-based community. If you know someone who is struggling with depression, ask how you might be able to provide support. In addition, while treatment for women who experience postpartum depression includes medication as well as therapy, support and early intervention are also important. Mothers' support groups, or groups specifically designed for women with postpartum depression, may be worth exploring to give the woman with postpartum depression a place to share her feelings. Other critical interventions include approaches that any mother with a newborn needs: nutritious, regular meals; light exercise; a few hours without childcare responsibilities; and extra sleep to combat exhaustion. Support is an important component in the road to recovery for all forms of depression.

Prevention

Self-help strategies play an important role in maintaining mental health. Among the most useful are:

• Exercise. Aerobic workouts such as walking or jogging can keep your mood elevated and help prevent bouts of depression. Even non-aerobic exercise, such as weight-lifting, can keep your spirits high, improve sleep and appetite, reduce irritability and anger and produce feelings of mastery and accomplishment. Be sure to check with your health care professional before you start an exercise program.
• Tune into your problems. Analyze recent events to identify possible sources of stress, either alone or with a close friend or loved one, to help you regain a better perspective. However, if you find yourself focusing too much on a problem, try another technique because thinking about the problem excessively can lead to depression.
• Self-talk. If your inner voice is constantly critical, try to make note of unrealistically negative or critical remarks and focus more on the things you like about yourself.
• Journaling. Write about problems and concerns in a journal to ease your anxiety and help you work through painful feelings. To get started, reflect upon each day or week and identify the most meaningful moments. If you experience an intense emotion, positive or negative, write down the circumstances and the effects of the experience. Analyze any encounter that makes you feel bad.
• Meditation. Meditation involves daily contemplation in a quiet place. There are many forms of mediation, both religious and secular. All of them involve a focal point and repeated practice. This can lead to a state of relaxation as well as a distraction from everyday worries and concerns.
• Self-help or support groups. Talk with people with similar problems through hospital- or community health-sponsored support groups. Such groups can help prevent depression recurrences.

The Holiday Blues

The holidays are a stressful time of year for many people. The "holiday blues" are a common response to the additional responsibilities the holiday season can impose. Additionally, you may feel loss more acutely during the holidays as you remember loved ones who have died.

Symptoms of the holiday blues can include feeling overwhelmed, anxious or angry; crying spells; withdrawal; or self-medicating with food or alcohol. While these symptoms can be similar to those experienced by someone who is clinically depressed, they are temporary. Depression is not. If holiday blues become incapacitating and/or persist for two or more weeks, professional help is advised. Some simple interventions can help you prepare for the holiday hustle, minimize stress and keep the holidays healthy:

• Talk about the person you're missing.
• Plan ahead and prioritize activities.
• Be realistic about what can be accomplished in the upcoming weeks.
• Alter a tradition that is particularly uncomfortable or overwhelming.
• Be honest about feelings.
• Focus on something positive and not a memory of a negative experience.
• Take time off for yourself.
• Recognize that alcohol, cigarettes and caffeine increase stress; limit use of these substances.
• Exercise, eat nutritiously and get enough sleep to prevent exhaustion.
• If you don't have a support network during the holidays, try to join others in a community center, book club or religious service or activity.

Facts to Know

1. Depression afflicts more than 12 million American women each year and strikes women twice as often as men. Biological differences in women, such as hormonal changes and genetic factors, may contribute to higher rates of depression. Stress experienced by women from work- and family-related responsibilities, poverty or abuse may also play a role. After one episode of depression, a woman has a 50 percent chance of experiencing another episode. After she has experienced two bouts of major depression, a woman has a 70 percent chance of experiencing a third. And after three episodes of depression, a woman has a 90 percent chance of experiencing a fourth.
2. Depression is not something you can just "get over." It is a complex medical condition. Depression is thought to be triggered by low levels of certain brain chemicals called neurotransmitters. Serotonin, one example of a neurotransmitter, has been identified as a major player in depression and other mental illnesses.
3. Prolonged stress, loss, substance abuse, some medications and certain illnesses can trigger depression in people who are susceptible to it. Depression also can occur spontaneously, without any apparent trigger.
4. Antidepressant medications can greatly relieve symptoms for most people who suffer from depression. Newer medications with fewer side effects have been developed in the last decade, offering more options for people with this illness.
5. Depression is likely to show up in more than one family member or generation.
6. Depression often strikes between the ages of 25 and 44; teenagers may also develop depression. It can last for weeks, months, years or a lifetime, if not diagnosed and treated. Anyone—regardless of income, education or status—can suffer from this disease.
7. Depression often gets translated into physical complaints. It can be mistaken for other illnesses by both a health care professional and the patient herself, instead of being properly recognized and diagnosed.
8. About 7 percent of men and 1 percent of women with a lifetime history of depression will commit suicide. If not treated, depression can spiral into feelings of worthlessness, despair and suicide. Early intervention and treatment can reverse these feelings and make life seem livable again.
9. Within six months of giving birth, about 10 to 15 percent of women report diagnosable postpartum depression, which is more severe and long-lasting than the "baby blues." If you've had prior depressive episodes, you have a much higher risk.
10. Chronic but mild depression, or dysthymia, is marked by low energy, a general negativity and a sense of dissatisfaction and hopelessness. A person suffering from dysthymia may experience many of the same symptoms that occur in major depression, but they are less intense and last much longer—at least two years.

Questions to Ask

Review the following Questions to Ask about depression so you're prepared to discuss this important health issue with your health care professional.

1. Do I have depression? What kind of depression do I have?
2. Could my depression be caused by an underlying medical condition or by medications I'm taking?
3. Should I see a psychiatrist to determine if medication might help me?
4. If medication is prescribed, how long before the drug begins to help me? How will I know if it is helping?
5. Is this medication safe for me to take given my current situation? Is it safe with other medications I'm taking? Does it have any side effects I should be aware of?
6. How long will I need to take this medication?
7. Should I avoid other medications, alcohol or certain foods while I take this medication?
8. What if this medication doesn't work? Should I call you and come in for another visit before stopping the medication?
9. What if I can't tolerate the side effects of this medication? Should I call you and come in for another visit before stopping it?
10. Will you be counseling me or referring to me to counseling, as well as prescribing medication? What should I do if I believe I need counseling or other types of support?
11. Is the medication you're prescribing for me in any way addictive? Are there any substances, like alcohol, that I should stay away from while taking my medication?
12. What should I do if I find myself thinking of suicide?

Key Q&A

Lifestyle Tips

1. Coping with holiday depression
   Feelings of depression can strike not only during the winter holidays, but also on any occasion with high social and emotional expectations. Begin by understanding that you are not obligated to feel cheerful or any particular way; accept your feelings so you can deal with them. Understand that one reason for your sadness may have to do with missing people who have died, either recently or even years ago. Avoid alcohol or other substances if they serve as "quick fixes"—they do more harm than good. Don't spend extra money either. Share responsibility for preparing for a social event rather than taking it all on yourself. Make time for yourself to "recharge" and relieve stress. If you're lonely, volunteer to help others.
2. What to do when depression starts
   Think of specific triggers that might be causing or aggravating your depression. Some examples are sleep deprivation, diet deficiencies, seasonal light deprivation, stress, grief due to loss, alcohol abuse, problems in relationships and medications. Change the factors that you can, and bring others to the attention of your health care professional. Take care of yourself with a healthy diet, adequate sleep and moderate exercise. Don't withdraw, but maintain only a reasonable amount of responsibilities. See your health care professional, go to a walk-in center or call a hotline for the help you need. Let your family and friends help you.
3. What to do while waiting for your medication to start working
   Break large tasks into small ones and set priorities to make your day less frustrating. You may also find that it's easier to do physical tasks (like cleaning) than analytical tasks, and these still accomplish something useful. Choose non-stressful activities that normally make you feel good, like going to a movie, a religious service or a ballgame. Moderate exercise may help. Consciously turn to more positive thoughts when you find yourself concentrating on the negative. Ask friends and family for support. Take your medication as prescribed and expect your mood to lift gradually, not suddenly. Call your health care provider if you have questions or concerns.
4. Put the light back in your life
   If you have seasonal affective disorder (SAD) or "winter depression," don't use tanning beds as light therapy. The ultraviolet rays they give off may be harmful to your eyes and skin. Instead, try light boxes, wearable visors and even masks specially made as SAD therapy. These light sources are much brighter than ordinary indoor light. Sit about two feet away and read or do whatever you wish for about 30 minutes per day. Mornings are best. Don't use the treatment too late in the evening, or you may have trouble sticking to your normal sleeping hours.
5. What to do if you think your child may have depression
   Talk to your child. Pay attention to behavioral changes like crying more often, irritability, complaining of feeling sad and empty, discouragement and hopelessness, disrupted sleep, loss of interest in favorite activities, a change in school performance, isolation from friends and family. Remember that even a child with good grades can be depressed, if he or she is trying to compensate for low self-esteem by being anxious to please. School-age children may complain of headache or stomachache or may act irritable or misbehave. Teens may behave recklessly. Consult with your pediatrician, school guidance counselor or mental health professional and know the warning signs of suicide so you can act swiftly if you see them.

Organizations and Support

For information and support on coping with Depression, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Child and Adolescent Psychiatry (AACAP)
Website: https://www.aacap.org
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016-3007
Phone: 202-966-7300

American Association for Marriage and Family Therapy
Website: https://www.aamft.org
Address: 112 South Alfred Street, Suite 3000
Alexandria, VA 22314-3061
Phone: 703-838-9808
Email: central@aamft.org

American Association of Suicidology
Website: https://www.suicidology.org
Address: 5221 Wisconsin Avenue, NW
Washington, DC 20015
Hotline: 1-800-273-TALK (1-800-273-8255)
Phone: 202-237-2280
Email: info@suicidology.org

American Foundation for Suicide Prevention
Website: https://afsp.org/
Address: 199 Water St.
New York, NY 10038
Hotline: 1-888-333-AFSP (2377)
Phone: 212- 363-3500
Email:info@afsp.org

American Psychological Association
Website: https://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Association for Behavioral and Cognitive Therapies (ABCT)
Website: https://www.abct.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212 647-1890

Depression and Bipolar Support Alliance (DBSA)
Website: https://www.dbsalliance.org
Address: 730 N. Franklin Street, Suite 501
Chicago, IL 60610
Hotline: 1-800-826-3632
Email: info@dbsalliance.org

Federation of Families for Children's Mental Health
Website: https://www.ffcmh.org
Address: 9605 Medical Center Drive, Suite 280
Rockville, MD 20850
Phone: 240-403-1901
Email: ffcmh@ffcmh.org

Freedom From Fear
Website: https://www.freedomfromfear.org
Address: 308 Seaview Avenue
Staten Island, NY 10305
Phone: 718-351-1717
Email: help@freedomfromfear.org

Geriatric Mental Health Foundation
Website: https://www.gmhfonline.org
Address: 7910 Woodmont Ave, Suite 1050
Bethesda, MD 20814
Phone: 301-654-7850
Email: web@GMHFonline.org

Mental Health America
Website: https://www.mentalhealthamerica.net
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722

Mindwise Innovations
Website: https://www.mindwise.org/
Address: 270 Bridge Street Suite 205
Dedham MA, 02026
Phone: 781-239-0071
Email:info@mindwise.org

National Alliance on Mental Illness (NAMI)
Website: https://www.nami.org
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
Phone: 703-524-7600

National Institute of Mental Health
Website: https://www.nimh.nih.gov
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513
Email: nimhinfo@nih.gov

National Mental Health Consumers' Self-Help Clearinghouse
Website: https://www.mhselfhelp.org
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
Hotline: 1-800-553-4539
Phone: 215-751-1810
Email: info@mhselfhelp.org

Postpartum Support International
Website: https://www.postpartum.net
Address: P.O. Box 60931
Santa Barbara, CA 93160
Hotline: 1-800-944-4PPD (1-800-944-4773)
Phone: 805-967-7636
Email: psioffice@postpartum.net

SAMHSA's National Mental Health Information Center
Website: https://mentalhealth.gov/
Address: P.O. Box 2345
Rockville, MD 20847
Hotline: 1-800-789-2647
Phone: 240-221-4021

Books

10 Steps to Take Charge of Your Emotional Life: Overcoming Anxiety, Distress, and Depression Through Whole-Person Healing
by Dr. Eve A. Wood M.D.

50 Signs of Mental Illness: A Guide to Understanding Mental Health
by Dr. James Whitney Hicks M.D.

The American Medical Association Essential Guide to Depression
by AMA

Healing Depression: A Holistic Guide
by Catherine Carrigan , M.D. William G. Crook M.D. M.D., William G. Crook

How You Can Survive When They're Depressed - Living and Coping with Depression Fallout
by Anne Sheffield, Mike Wallace, Donald F. Klein

Living Well with a Hidden Disability: Transcending Doubt and Shame and Reclaiming Your Life
by Stacy Taylor, Robert Epstein

My Feelings Are Like Wild Animals! How Do I Tame Them?: A Practical Guide to Help Teens (& Former Teens) Feel & Deal with Painful Emotions
by Gary Egeberg

Postpartum Survival Guide
by Ann Dunnewold, Diane G. Sanford

Stop Depression Now: SAM-e, the Breakthrough Supplement That Works Better Than Prescription Antidepressants in Half the Time...With No Side Effects
by Richard Brown, Teodoro Bottiglieri, and Carol Colman

What the Blues Is All About - Black Women Overcoming Stress & Depression
by Angela Mitchell, Kennise Herring

Win the Battle: The 3-Step Lifesaving Formula to Conquer Depression and Bipolar Disorder
by Bob Olson

Women & Anxiety: A Step-by-Step Program for Managing Anxiety and Depression
by Helen DeRosis

Spanish-language resources

National Institute of Mental Health
Website: https://www.nimh.nih.gov/health/publications/espanol/depression-listing.shtml
Address: NIMH
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513

Medline Plus: Depression
Website: https://www.nlm.nih.gov/medlineplus/spanish/depression.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Womenshealth.gov
Website: https://espanol.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression
Address: National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA 22031
Hotline: 1-800-994-9662