Depression is a mood disorder in which feelings of loss, anger, sadness, or
frustration interfere with everyday life. Depression affects approximately 17
million Americans each year. It can be mild, moderate, or severe and occur as a
single episode, as recurring episodes, or as chronic depression (lasting more
than 2 years).
The primary types of depression include:
- Major depression—five or more symptoms must
be present; an episode must last at least 2 weeks, but tends to continue for 20
weeks. (A mood disorder is classified as minor depression if less than five
depressive symptoms are present for at least 2 weeks.)
- Dysthymia—a chronic, generally milder form of
depression; symptoms are similar to major depression but more mild in degree
- Atypical depression—depression accompanied by
unusual symptoms, such as hallucinations, delusions, and physical rigidity
Other common forms of depression include:
- Postpartum depression—experienced by 8% to
20% of women following delivery
- Premenstrual dysphoric disorder
(PDD)—experienced by 3% to 8% of women; depressive
symptoms occur 1 week prior to menstruation and disappear following
- Seasonal affective disorder (SAD)—experienced
by 5% of adults, the majority of whom are women; occurs during the fall-winter
season and disappears during the spring-summer season
Depression may also occur with mania (known as manic-depression or bipolar
disorder). In this condition, moods cycle between mania and
|Signs and Symptoms|
While it is normal for most people to feel "down in the dumps" on occasion, a
person with major depression feels significantly depressed for a prolonged
period of time, has difficulty enjoying acts that were once pleasurable, and
experiences at least five of the following symptoms for 2 weeks or
- Sleep disturbances—at least 90% of people
with depression have either insomnia (sleeplessness) or hypersomnia (excessive
- Significant change in appetite (often resulting in either weight loss
or weight gain)
- Fatigue and loss of energy
- Feelings of worthlessness, self-hate, and inappropriate
- Extreme difficulty concentrating
- Either agitation, restlessness, and irritability or inactivity and
- Recurring thoughts of death or suicide
- Feelings of hopelessness
Although not generally considered to be defining characteristics of
depression, many people with the condition report a lack of sex drive and sudden
bursts of anger.
The causes of depression are complex and involve a combination of biologic,
genetic, and environmental factors. People with depression may have abnormal
levels of certain brain chemicals, including serotonin, acetylcholine, and
catecholamines (such as dopamine). The following may alter the levels of these
brain chemicals and contribute to development of depression:
- Heredity—a recently identified gene called
SERT that regulates the brain chemical serotonin, has been linked to
- Chronic stress (such as from loss, abuse, or deprivation in early
- Amount of exposure to light
- Sleep disturbances
- Social isolation
- Nutritional deficiencies (especially folate [vitamin B9] and omega-3
- Serious medical conditions, such as heart attack or cancer
- Certain medications, including those for high blood pressure, high
cholesterol, or irregular heartbeat
Although depression is a condition that can affect anyone, regardless of age,
race, or gender, the following factors may increase an individual's risk for an
initial or recurrent episode of depression:
- Prior episodes of depression
- Family history of depression
- Suicide attempt—a former attempt of suicide
during a major depressive episode increases the likelihood of another episode of
- Female gender—the incidence of depression
appears to be greater in women than in men, however, some researchers speculate
that women may simply report their symptoms more frequently than men and that
men may be more apt to mask their depressive symptoms with alcohol. Therefore,
it is still unclear whether women truly have a greater risk for depression.
- Young adulthood or middle age—the highest
occurrence of depression is between the ages of 25 and 44; the elderly are also
at particular risk due to death of loved ones, physical illness, and loss of
- Stressful life events (such as the death of a loved one), particularly
if the event occurs at a young age
- Postpartum period
- Chronic medical or psychological conditions including autoimmune
diseases (such as lupus), cancer, heart disease, chronic headaches, chronic
pain, anxiety, obsessive-compulsive disorder, and borderline personality
disorder; medical conditions that cause shifts in hormones, such as thyroid
disorders or menopause, may also contribute to depression.
- History of abuse (such as mental, physical, or sexual)
- Lack of social support system (such as a network of close friends or
- Current or past alcohol or drug abuse—25% of
people with addictions have depression
If feelings of depression or any of the related symptoms are present, it is
important to address them with a physician or someone who can help direct care
appropriately. Unfortunately, many people with depression tend to refrain from
disclosing any or all of their symptoms in this setting. Occasionally, even when
the symptoms are discussed during an appointment, a physician may try to treat
them individually, rather than recognizing the complete picture of depression.
Working together with a primary care physician is extremely important, however,
because he or she is often the person who makes a referral to a psychiatrist
who, in turn, makes a definite diagnosis of depression. Proper diagnosis of
depression is the first step toward proper treatment.
Only psychiatrists can prescribe
medication, but psychologists and
social workers, as well as psychiatrists, use
psychotherapy as an important mode
of treatment. These specialists will often administer a screening test, such as
the Beck Depression Inventory or the Hamilton Rating Scale, which consists of
about 20 questions that assess an individual's risk for depression. Even before
these psychological screening tests, however, several blood tests will be
performed to determine whether nutrient deficiencies or underlying medical
conditions (such as a thyroid disorder) may be causing or contributing to
Although the vast majority of people with depression are treated as
outpatients, hospitalization is necessary for people who intend or attempt
suicide, and may be necessary under other circumstances as well.
The following steps can help prevent depression or decrease the chances of
- Adequate sleep,
regular exercise, and a balanced, healthy
diet may help prevent depression and
diminish symptoms of this mood disorder.
mind/body techniques, such as
biofeedback, meditation, and tai chi, are effective ways to prevent or reduce
symptoms associated with depression.
- Psychotherapy directed at coping
skills generally helps prevent relapse.
- Family therapy may prevent children or teens of depressed parents from
becoming depressed later in life.
- Compliance with the prescribed treatment regimen decreases the chance
People with depression have a number of options for treatment, but a
antidepressant medications is the
regimen of choice, particularly for people with major depression.
appears to be the most effective type of psychotherapy, particularly for
adolescents and people with atypical or postpartum depression. As many as 90% of
people with depression improve from a combination of psychotherapy and
antidepressants; however, adverse side effects from certain medications make it
difficult for many to take their medications. Some complementary and alternative
therapies may be helpful in reducing the side effects from such medications;
other complementary and alternative therapies may actually diminish the symptoms
of depression. The following, in the order indicated, may be considered under
the guidance of an appropriately trained specialist such as a psychiatrist or
Studies have consistently shown that regular exercise (either aerobic or
strength/flexibility training) significantly reduces depressive symptoms in
people with mild to moderate depression and improves the mood of people with
major depression. Some even suggest that exercise may be as effective as
psychotherapy for people with mild to moderate depression, although additional
research is needed to confirm this encouraging finding. In the meantime,
exercise can be used safely in conjunction with medication for those with
Studies suggest that people with depression who eat a healthy diet that
includes fatty fish (such as salmon, mackerel, herring, and sardines) two to
three times per week may significantly reduce their feelings of depression and
anxiety. Fatty fish contain omega-3 polyunsaturated fatty acids (PUFAs), and
many individuals with depression are deficient in this substance. Some studies
suggest that dietary supplementation with docosahexaenoic acid (DHA), one type
of PUFA, may help prevent depression.
Diets rich in fruits and vegetables, particularly leafy green vegetables, are
also recommended for people with depression. For those who have difficulty
maintaining a balanced diet, supplementation with a multivitamin may also be
Antidepressant medications are very effective; reports indicate that they are
90% successful in treating depression. In general, medications are taken for at
least 4 to 6 months to assure complete and effective treatment. However,
antidepressants often cause adverse side effects, making it difficult for some
people to comply with taking their medications. Medications must not be stopped
without first discussing this change with a physician. Most antidepressants
cause withdrawal symptoms if they are not discontinued slowly over time with
guidance from a physician.
There are several classes of antidepressant medications, including:
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs increase the activity of a chemical in the brain called serotonin. Most
healthcare practitioners will prescribe SSRIs before any other antidepressant
medication for depression, in part because the side effects associated with
SSRIs are generally fewer than for other classes of antidepressants. Typical
side effects caused by SSRIs include stomach upset, weight gain or loss,
drowsiness, sexual dysfunction (such as impotence, decreased libido, and
diminished orgasm), headache, jaw grinding, and apathy. Very unusual side
effects from this class of prescription drugs include extreme agitation,
impulsivity, tremors, and insomnia. People who discontinue taking SSRIs due to
side effects usually attribute their discontent to sexual dysfunction.
Drugs classified as SSRIs include:
- Paroxetine—most likely in this class to cause
- Citalopram—least likely in this class to
cause sexual dysfunction
Another group of antidepressant medications (which are similar to SSRIs, but
target other brain chemicals in addition to serotonin) may cause fewer negative
sexual side effects. These include:
- Bupropion—should not be used if there is
history of or risk for seizure
- Nefazodone—no sexual dysfunction reported;
begins to work very quickly; may cause a decrease in blood pressure when going
from lying or sitting to standing
- Venlafaxine—may impair sexual function; not
recommended in the elderly; may improve quality of life more effectively than
other antidepressants, but can cause irregular heart rhythm; withdrawal from the
medication is difficult
- Mirtazapine—may be particularly effective if
feelings of anxiety are also present; helps with insomnia but may cause
drowsiness; other side effects are blurred vision, weight gain, and damage to
production of cells in the bone marrow (very rare)
- Maprotiline—may cause dry mouth, drowsiness,
sensitivity to the sun, and seizures
Tricyclics increase the activity of the brain chemicals serotonin and
norepinephrine. They are as effective as SSRIs, but are usually prescribed only
to those who do not respond well to SSRIs because side effects are quite common
and are usually less tolerable. Dry mouth, blurred vision, constipation, sexual
dysfunction, weight gain, dizziness, drowsiness, urinary urgency (a sense that
one has to urinate even when the bladder is empty), drop in blood pressure when
going from lying or sitting to standing (causes dizziness and lightheadedness),
and irregular heart rhythm are among the side effects of tricyclics.
Tricyclic antidepressants include:
- Amoxapine—increases risk of seizure in those
who are prone to have a seizure
- Clomipramine—used for obsessive/compulsive
- Doxepin—may help with insomnia
- Imipramine—may cause a rare lung disorder
called idiopathic pulmonary fibrosis
- Nortriptyline—less risk of irregular heart
rhythm than others in this class
- Protriptyline—less drowsiness than others in
this class and may even cause weight loss; may lead to sun
- Trimipramine—high risk for irregular heart
Monoamine Oxidase Inhibitors (MAOIs)
MAOIs boost the levels of norepinephrine, dopamine, and serotonin in the
brain. MAOIs are generally prescribed only when other antidepressants have not
been effective, which may occur in people with atypical depression. People who
take MAOIs may experience a sharp increase in blood pressure after consuming
food or drink containing the amino acid tyramine (found in such foods as aged
cheeses and red wine). MAOIs also negatively interact with other medications,
including ritalin (used for attention deficit hyperactivity disorder) and
pseudoephedrine (decongestant in many over the counter and prescription
medications), and should not be taken with other classes of antidepressants.
- Phenelzine—should be avoided with a history
of seizures or bipolar disorder (manic-depression)
- Isocarboxazid—side effects include
drowsiness, sexual dysfunction, weakness, trembling, and blurred
- Tranylcypromine—should not be used if there
is any history of kidney disease or bipolar
|Surgery and Other Procedures|
- Electroconvulsive Therapy (ECT) for depression is usually reserved for
cases in which all other therapies have been unsuccessful. In this procedure, a
small electrical current induces a seizure lasting approximately 40 seconds. A
muscle relaxant and mild sedative are administered prior to the procedure. ECT
is generally repeated every 2 to 5 days for a total of six treatments. It may
cause temporary confusion, memory impairment, headache, muscle aches, irregular
heart rhythm, or nausea.
- Magnetic Resonance Imaging (MRI)-Guided Cingulotomy involves the
application of an electrical current to a specific part of the brain; the MRI is
used as a guide for an exact placement. Long-term improvement has been reported
using this technique in over 50% of people with depression who have not
responded to other modes of therapy.
|Nutrition and Dietary Supplements|
Certain nutrients and dietary supplements have been associated with
Folate (Vitamin B9)
Studies suggest that folate may be associated with depression more than any
other nutrient. Between 15% and 38% of people with depression have low folate
levels in their bodies and those with very low levels tend to be the most
depressed. Having low levels of folate may also affect treatment; some studies
report that people with folate deficiencies tend to respond less effectively to
the SSRI, fluoxetine, than those with normal amounts of folate. Therefore,
folate supplementation (typically between 400 and 800 mg) may be useful in both
treating depression and assuring the appropriate effects of some antidepressant
Many healthcare providers start by recommending a multivitamin (MVI) that
contains folate, and then monitoring the homocysteine levels in the blood to
ensure the adequacy of therapy. Elevated homocysteine levels indicate a
deficiency of folate even if the levels of folate in the blood are normal. If
the MVI alone is not enough to lower homocysteine and improve folate function,
the provider may suggest additional folate along with vitamins B6 and B12.
Omega-3 fatty acids
Essential fatty acids, such as omega-3 and omega-6 fatty acids play a crucial
role in the function of brain chemicals, particularly serotonin and dopamine.
Studies have shown that low levels of omega-3 fatty acids (found in cold-water
fish such as tuna and salmon), or a high ratio of omega-6 fatty acids (found in
certain vegetable oils, such as corn and soybean oils) to omega-3 fatty acids,
may be associated with depression. A typical American diet is high in omega-6
compared to omega-3 fatty acids. Eating foods rich in omega-3 fatty acids on a
regular basis helps maintain an appropriate balance of omega-6 to omega-3 fatty
acids, and although unproven, restoring this balance may help with feelings and
symptoms of depression.
Some studies suggest that the dietary supplement SAMe may be just as
effective as tricyclic antidepressants for treating depression, but with fewer
side effects. SAMe appears to boost serotonin levels in the brain, but further
research investigating the mechanism of action (how it works), safety, and
effectiveness of SAMe for depression is warranted. Until more is understood, it
is best to avoid using SAMe in conjunction with other antidepressants. Discuss
its use with your healthcare provider who can help tailor your treatment
Tryptophan is an amino acid involved in the production of serotonin. Studies
suggest that tryptophan depletion can lead to diminished serotonin levels, and
in some cases, may increase a person's susceptibility to depression. Some
research indicates that tryptophan, together with tricyclic medications, may
produce better results than the medication alone. Tryptophan supplementation
alone may not be enough to reduce symptoms of depression. However, while
research results are intriguing, tryptophan use has been associated with the
development of serious conditions such as liver and brain toxicity, and with
eosinophilic myalgia syndrome (EMS), a potentially fatal disorder that affects
the skin, blood, muscles, and organs. (An outbreak of EMS caused by a
contaminated batch of tryptophan led to the removal of this supplement from the
United States market in 1989.) In addition, given the possibility of adverse
interactions, tryptophan should not be used in conjunction with MAOIs or
Some studies suggest that a by-product of tryptophan known as 5-HTP may be as
effective as SSRIs and tricyclic antidepressants in treating depression, but
with fewer side effects. As with tryptophan, EMS has been reported in 10 people
taking 5-HTP. Further research is necessary to determine whether supplementation
with 5-HTP is safe and effective for the treatment of depression.
Some reports indicate that the mineral selenium, found in wheat germ,
brewer's yeast, liver, fish, shellfish, garlic, sunflower seeds, Brazil nuts,
and grains, significantly affects mood. In one study of people with low levels
of selenium, those who consumed a diet high in selenium reported decreased
feelings of depression after 5 weeks.
Inositol is a naturally occurring substance involved in the production of
certain brain chemicals. In a few studies, levels of inositol were lower in the
cerebrospinal fluid (fluid surrounding the brain and spinal column) of depressed
people compared to healthy people. In addition, administration of inositol
decreased signs of depression in two animal studies. Several small human studies
suggest that inositol may be of value in the treatment of depression,
particularly for those who do not respond to antidepressant medications. More
clinical trials are necessary to draw definitive conclusions on this substance,
A number of studies conducted in the 1970s showed encouraging results
regarding the use of tyrosine to ease symptoms of depression. In one study from
1990, however, tyrosine failed to demonstrate any anti-depressant activity. More
studies are needed in order to draw firm conclusions about the use of tyrosine
to help treat mild to moderate depression.
In one study of only 10 people with seasonal
affective disorder, those who received melatonin supplements had significant
improvement in their symptoms compared to those who received placebo. Given the
small size of this study, however, more research is needed before conclusions
can be drawn regarding use of melatonin for either seasonal affective disorder
or any other type of depression.
Some healthcare professionals recommend vitamin C to reduce the symptom of
dry mouth, a side effect experienced by many people taking antidepressant
While many herbal remedies have been used traditionally to treat depression,
the most substantial amount of scientific research has involved the following
St. John's wort (Hypericum perforatum)
Several studies indicate that St. John's wort may be as effective as
tricyclic antidepressants, but with fewer side effects. Reported side effects
include gastrointestinal complaints, fatigue, and oversensitivity to sunlight.
Because of potential adverse interactions, St. John's wort should not be taken
in conjunction with other antidepressants or with certain medications, including
indinivir (a protease inhibitor used for HIV), oral contraceptives,
theophylline, warfarin, digoxin, reserpine, cyclosporine, and loperamide.
Although they have yet to be scientifically evaluated for their use in
treating depression, the following are a few examples of herbs that may be
recommended by professional herbalists for depression or its related symptoms:
- Valerian root (Valerian
officinalis)—may improve symptoms of insomnia
associated with depression
- Damiana (Turnera
diffusa)—may reduce sexual dysfunction
associated with many antidepressant medications
- Ginseng (Panax
ginseng)—may help the body resist stress
Two randomized, controlled, clinical trials suggest that electroacupuncture
may reduce symptoms of depression as effectively as amitryptiline, a tricyclic
antidepressant medication. Electroacupuncture involves the application of a
small electrical current through acupuncture needles. Other studies suggest that
acupuncture may be effective for people with mild depression and for those with
depression related to a chronic medical illness. Further research is warranted
in this area.
Although very few studies have examined the effectiveness of specific
homeopathic therapies, professional homeopaths may consider the following
remedies to alleviate the symptoms of depression based on their knowledge and
experience. Before prescribing a remedy, homeopaths take into account a person's
constitutional type. A constitutional type is defined as a person's physical,
emotional, and psychological makeup. An experienced homeopath assesses all of
these factors when determining the most appropriate treatment for each
- Ignatia -- for a sudden sense of grief or disappointment
following the death of a loved one, the end of a romantic relationship, or an
unexpected loss of one's job; this remedy is most appropriate for individuals
who are very sad and have frequent crying spells
- Natrum muriaticum -- for grief following the death of a loved
one or sadness from the end of a romantic relationship; this remedy is most
appropriate for individuals who grieve silently and desire to be alone, avoid
being comforted, and are reluctant to cry in
|Massage and Physical Therapy|
Studies of formerly depressed adolescent mothers, children hospitalized for
depression, and women with eating disorders, suggest that massage decreases
stress hormone levels, feelings of anxiety, and symptoms of depression. Giving
massage may also be beneficial for people who are depressed. Elderly volunteers
with depression showed notable improvement in their symptoms when they massaged
Aromatherapy, or the use of essential oils in massage therapy, may also be of
value as a supplemental treatment for depression. Theoretically, the smells of
the oils elicit positive emotions through the limbic system (the area of the
brain responsible for memories and emotions). However, the benefits of
aromatherapy appear to be related to the relaxation effects of the treatment as
well as to the recipient's belief that the treatment will be beneficial.
Essential oils used during massage for depression are quite varied and
- Basil (Ocimum basilicum)
- Orange (Citrus aurantium)
- Sandalwood (Santalum album)
- Lemon (Citrus limonis)
- Jasmine (Jasminum spp.)
- Sage (Salvia officinalis)
- Chamomile (Chamaemelum nobile)
- Peppermint (Mentha piperita)
Mind/body therapies and techniques that may be useful as a part of an overall
treatment regimen for depression include:
Cognitive-behavioral therapy is a type of psychotherapy in which individuals
learn to identify and change distorted perceptions about themselves and adapt
new behaviors to better cope with the world around them. This therapy is
frequently considered the treatment of choice for people with mild to moderate
depression, but it may not be recommended for those with severe depression.
Studies of people with depression indicate that cognitive-behavioral therapy is
at least as effective as tricyclic antidepressants. Compared to those treated
with antidepressants, people treated with cognitive-behavioral therapy
demonstrated similar, or better, results and lower relapse rates.
Other therapeutic approaches that may be applied by a psychiatrist,
psychologist, or social worker include:
- Psychodynamic psychotherapy—based on Freud's
theories about unresolved conflicts in childhood and depression as a grief
- Interpersonal therapy—acknowledges childhood
roots of depression, but focuses on current problems contributing to depression;
considered very effective treatment for depression
- Supportive psychotherapy—nonjudgmental
advice, attention, and sympathy; this approach may improve compliance with
One study suggests that relaxation techniques, such as yoga and tai chi, may
improve symptoms of depression in people with mild depression.
Some researchers theorize that mindfulness meditation may prevent depression
from recurring in people who once had the
- Postpartum depression is experienced by 8% to 20% of women following
- The safety of SSRIs and tricyclic antidepressant medications during
pregnancy remains uncertain. The physician will provide guidance regarding use
or avoidance of antidepressants during pregnancy. The risks and benefits to the
mother and the fetus must be weighed in each individual case in order to
determine the most appropriate regimen during pregnancy. MAOIs cause birth
defects and should be avoided during pregnancy.
- The dietary supplements and herbs mentioned here have not been tested
for safety during pregnancy, and should therefore be
|Warnings and Precautions|
- SSRIs should be avoided in people with Parkinson's disease.
- Tricyclic antidepressants should be avoided in people with coronary
- Several herbal remedies and supplements should not be combined with
antidepressant medications. Be sure to inform your healthcare provider of all
herbs and supplements you take to avoid adverse
|Prognosis and Complications|
Depression is a serious condition that can have a devastating effect on
people's lives. It can directly and indirectly contribute to chronic medical
conditions, such as heart disease and stroke, because depressed people with
these conditions are less likely to engage in healthy behaviors (such as
exercise) and more likely to engage in unhealthy behaviors (such as smoking).
Suicide is a significant factor in depression; about 15% of people with major
depressive disorder commit suicide. Depression also significantly shortens the
life-span of the elderly and is associated with the development of memory
impairment and dementia.
When left untreated, depression can last up to 2 years. Rates of recurrence
are variable: 50% of people who have had one depressive episode will have a
second major depressive disorder; 70% will have a third and 90% will have a
fourth. Symptoms of depression usually disappear after menopause in women with
premenstrual dysphoric disorder or seasonal affective disorder. Fortunately,
there are several treatment options available for people with depression and the
prognosis improves tremendously for those who seek treatment and comply with
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|Review Date: March 2001|
|Reviewed By: Participants in the review process include: John Balletto, LMT, NCTMB, Center
for Muscular Therapy, President, Providence, RI; Jacqueline A. Hart, MD,
Department of Internal Medicine, Newton-Wellesley Hospital, Harvard University
and Senior Medical Editor Integrative Medicine, Boston, MA; Lonnie Lee, MD,
Internal Medicine, Silver Springs, MD; Andrew Littman, MD, Psychiatry
Department, Massachusetts General Hospital, Boston,
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