CRIS

 Depression
       Defined
       Facts
       Evaluation
       Treatment
       Suicide

Depression

Serious depression is an important public health problem. More than 19 million adults in the United States will suffer from a depressive illness this year, and many will be unnecessarily incapacitated for weeks or months, because their illness goes untreated. The cost to the Nation in 1990 was estimated to be between $30 - $44 billion. The suffering of depressed people and their families is immeasurable.  

Depressive disorders are not the normal ups and downs that everyone experiences. They are illnesses that affect mood, body, behavior, and mind. Depressive disorders interfere with individual and family functioning. The person with a depressive disorder is often unable to fulfill the responsibilities of spouse or parent, and may be unable to carry out usual job responsibilities.  

Available medications and psychological treatments, alone or in combination, can help 80 percent of those with depression. With adequate treatment, future episodes may be prevented or reduced in severity. Yet, current evidence indicates that nearly two out of three depressed people do not seek treatment and suffer needlessly. 

Research has also shown that depression often co-occurs with medical conditions (e.g., stroke, heart disease, cancer, diabetes, etc.); other psychiatric disorders (e.g., anxiety disorders, eating disorders, etc.); and alcohol and other substance abuse. In such cases, there can be added health benefits from treating the depression.  

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Quick Facts

• Clinical depression is a common illness that usually goes unrecognized. When identified, it can be treated.
• There are effective medications and psychological treatments, which often are used in combination. In serious depression, medication is usually required.
• The majority of clinical depressions, including the most severe, improve with treatment, usually within weeks. Continued treatment will prevent recurrence.
• Depression is often unrecognized when it co-occurs with other medical, psychiatric, or substance abuse disorders.

Depressive Illnesses are Serious but Treatable Disorders 

• Depressive illnesses are more than temporary "blue" moods or periods of grief after a loss. 
• Symptoms of depression affect thoughts, feelings, body, and behaviors. 
• Without treatment, the symptoms can last for months, years, or a lifetime. 

Depressive Illnesses come in Various Forms 

• Some depressive episodes occur suddenly for no apparent reason. 
• Some are triggered by a stressful experience. 
• Some people have one episode in a lifetime; others, recurrent episodes. 
• Some people's symptoms are so severe they are unable to function as usual. 
• Others have ongoing, chronic symptoms that do not interfere with functioning, but keep them from feeling really well. 
• Some people have bipolar disorder (also called manic-depressive illness). They experience cycles of terrible "lows" and inappropriate "highs." 

Over 19 Million American Adults Suffer from Depressive Illnesses 

Depressive illnesses take a staggering toll: 

• They cause great pain to millions of people. 
• The lives of families and friends are affected, often seriously disrupted. 
• They hurt the economy, costing an estimated $30.4 billion in 1990. 

Many do not Recognize their Illness 
Nearly two-thirds of depressed people do not get appropriate treatment because their symptoms:

• Are not recognized.
• Are blamed on personal weakness. 
• Are so disabling that people cannot reach out for help. 
• Are misdiagnosed and wrongly treated. 

Symptoms of Depression can Include: 

• Persistent sad or "empty" mood 
• Loss of interest or pleasure in ordinary activities, including sex
• Decreased energy, fatigue, being "slowed down"
• Sleep disturbances (insomnia, early-morning waking, or oversleeping) 
• Eating disturbances (loss of appetite and weight, or weight gain) 
• Difficulty concentrating, remembering, making decisions 
• Feelings of guilt, worthlessness, helplessness 
• Thoughts of death or suicide; suicide attempts 
• Irritability 
• Excessive crying 
• Chronic aches and pains that don't respond to treatment 

Symptoms of mania can Include 

• Excessively "high" mood 
• Irritability 
• Decreased need for sleep
• Increased energy and activity 
• Increased talking, moving, and sexual activity 
• Racing thoughts 
• Disturbed ability to make decisions 
• Grandiose notions 
• Being easily distracted 

In the Workplace, Depression often may be recognized by: 

• Decreased productivity 
• Morale problems 
• Lack of cooperation 
• Safety problems, accidents
• Absenteeism 
• Frequent complaints of being tired all the time 
• Complaints of unexplained aches and pains 
• Alcohol and drug abuse

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Evaluation

Get an Accurate Diagnosis 
A thorough diagnosis is needed if five or more of the symptoms of depression or mania persist for more than two weeks, or are interfering with work or family life. A good diagnosis involves a complete physical checkup and a review of family history of health problems.

Most People can be Helped Quickly

• Depression with Other Illnesses: Depression often co-occurs with medical, psychiatric, and substance abuse disorders, though it is frequently unrecognized and untreated. This can lead to unnecessary suffering since depression is usually treatable, even when it co-occurs with other disorders. 
• Individuals or family members with concerns about the co-occurrence of depression with another illness should discuss these issues with the physician. 
• With available treatment, 80 percent of the people with serious depression--even those with the most severe forms--can improve significantly. Symptoms can be relieved, usually in a matter of weeks. 
• There are effective medications and psychotherapies(talk therapies) treatments that often are used in combination. In severe depression, medication is usually required.  A number of short-term talk therapies to treat clinical depression have been developed in recent years.  Several types of medications are available, none of them habit-forming. People with severe depression respond more rapidly and more consistently to medication. Those with recurring depression, including bipolar disorder, may need to
• stay on medication to prevent or lessen further episodes.  Many patients need psychotherapy to deal with the psychological or interpersonal problems often associated with their illness. 
• Other biological treatments can be helpful. For example, electroconvulsive treatment (ECT) is a safe and often effective treatment for the most severe depressions. Research is also being done on the use of light for the treatment of depression. 
• Early intervention may lessen severity of symptoms and shorten the episode. Individuals respond differently to treatment. if after several weeks symptoms have not improved, the treatment plan should be re-evaluated.  Individuals respond differently to treatments. If after several weeks symptoms have not improved, the treatment plan should be discussed with the doctor. 

Cost of Depression can be reduced 
When diagnosed early in the course of the illness, depressed people usually can be treated on an outpatient basis and improve productivity, avoid lost work time, and reduce high costs for: 

• Prolonged treatment, 
• Hospitalization, 
• Treatment of other physical and mental disorders resulting from untreated depression. 

Evaluation and Treatment can be received from: 

• Physicians 
• Mental health specialists 
• Employee assistance programs (EAPs) 
• Health maintenance organizations 
• Community mental health centers 
• Hospital departments of psychiatry or outpatient psychiatric clinics 
• University- or medical school-affiliated programs 
• State hospital outpatient clinics 
• Family service/social agencies 
• Private clinics and facilities 
• In addition to treatment, joining a support group may be helpful 

Depressed Persons may need to get help
The very nature of depressive illnesses can interfere with a person's ability or wish to get help. Depression saps energy and self-esteem and makes a person feel tired, worthless, helpless, and hopeless. 

• Seriously depressed people need encouragement from family and friends to seek treatment to ease their pain.
• Some people need even more help, becoming so depressed; they must be taken for treatment.

The Invisible Disease---Depression
 Depression is a serious medical illness. In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is persistent and can interfere significantly with an individual's ability to function. 

Symptoms of depression include sad mood, loss of interest or pleasure in activities that were once enjoyed, change in appetite or weight, difficulty sleeping or oversleeping, physical slowing or agitation, energy loss, feelings of worthlessness or inappropriate guilt, difficulty thinking or concentrating, and recurrent thoughts of death or suicide. A diagnosis of unipolar major depression (or major depressive disorder) is made if a person has five or more of these symptoms and impairment in usual functioning nearly every day during the same two-week period. Major depression often begins between ages 15-30 or even earlier. Episodes typically recur.

Some people have a chronic but less severe form of depression, called dysthymia (or dysthymic disorder) that is diagnosed when depressed mood persists for at least two years and is accompanied by at least two other symptoms of depression. Many people with dysthymia also have major depressive episodes. While unipolar major depression and dysthymia are the primary forms of depression, a variety of other subtypes exist. 

Depression can be devastating to all areas of a person's everyday life, including family relationships, friendships, and the ability to work or go to school. Many people still believe that the emotional symptoms caused by depression are "not real," and that a person should be able to shake off the symptoms if only he or she were trying hard enough. Because of these inaccurate beliefs, people with depression either may not recognize that they have a treatable disorder or may be discouraged from seeking or staying on treatment because of feelings of shame and stigma. Too often, untreated or inadequately treated depression leads to suicide. 

• Depression affects nearly 10 percent of adult Americans ages 18 and over in a given year, or more than 19 million people in 1998.
• Unipolar major depression is the leading cause of disability in the United States and worldwide. 
• Nearly twice as many women (12 percent) as men (7 percent) are affected by a depressive illness each year. 
• Evidence from studies of twins supports the existence of a genetic component to risk of depression. Across six studies, the average concordance rate in identical twins (40%) for unipolar depression is more than twice the concordance rate in fraternal twins (17%). 

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Treatment
Antidepressant medications are widely used, effective treatments for depression. Existing antidepressant drugs are known to   influence the functioning of certain neurotransmitters (chemicals used by brain cells to communicate), primarily serotonin, norepinephrine, and dopamine, known as monoamines. Older medications - tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) - affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they   can be difficult to tolerate due to side effects or, in the case of MAOIs, dietary and medication restrictions. Newer medications,   such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for   patients to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will   respond to one type of drug, but not another. Medications that take entirely different approaches to treating depression are now in   development. 

Electroconvulsive therapy (ECT), although not generally used as a first-line treatment, is one of the effective treatments for severe   depression. 

Psychotherapy is also effective for treating depression. Certain types of psychotherapy, cognitive-behavioral therapy (CBT) and   interpersonal therapy (IPT), have been shown to be particularly useful. More than 80 percent of people with depression improve   when they receive appropriate treatment with medication, psychotherapy, or the combination. 

Recently there has been enormous interest in herbal remedies for various medical conditions including depression. One herbal   supplement, hypericum or St. John's Wort, has been promoted as having antidepressant properties. However, no carefully   designed studies have determined the antidepressant efficacy of the supplement. NIMH is currently enrolling patients in the first   large-scale, multi-site, controlled study of St. John's wort as a potential treatment for depression. 

Recent Research Findings 
Modern brain imaging technologies are revealing that in depression, neural circuits responsible for moods, thinking, sleep, appetite, and behavior fail to function properly, and that the regulation of critical neurotransmitters is impaired. Genetics research   indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors.   Studies of brain chemistry, mechanisms of action of antidepressant medications, and the cognitive distortions and disturbed   interpersonal relationships commonly associated with depression, continue to inform the development of new and better   treatments. The hormonal system that regulates the body's response to stress - the hypothalamic-pituitary-adrenal (HPA) axis - is overactive in many patients with depression. The hypothalamus, the brain region responsible for managing hormone release   from glands throughout the body, increases production of a substance called corticotropin releasing factor (CRF) when a threat to   physical or psychological well-being is detected. Elevated levels and effects of CRF lead to increased hormone secretion by the   pituitary and adrenal glands, which prepares the body for defensive action. The body's responses include reduced appetite, decreased sex drive, and heightened alertness. Research suggests that persistent over activation of this hormonal system may   lay the groundwork for depression. The elevated CRF levels detectable in depressed patients are reduced by treatment with   antidepressant drugs, and this reduction corresponds to improvement in depressive symptoms.

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Suicide Facts
Suicide is a complex behavior usually caused by a combination of factors. Research shows that almost all people who kill themselves have a diagnosable mental or substance abuse disorder or both, and that the majority have depressive illness. Studies indicate that the most promising way to prevent suicide and suicidal behavior is through the early recognition and treatment of depression and other psychiatric illnesses. 

Most people who are depressed do not kill themselves. Suicide is considered a possible complication of depressive illness in combination with other risk factors because suicidal thoughts and behavior can be symptoms of moderate to severe depression. These symptoms typically respond to proper treatment, and usually can be avoided with early intervention for depressive illness. Any concerns about suicidal risk should always be taken seriously and evaluated by a qualified professional immediately. 

Suicide Risk Factors 
It is important to note that many people experience one or more risk factors and are not suicidal. 

•  One or more diagnosable mental or substance abuse disorder  Impulsivity  Adverse life events  Family history of mental or substance abuse disorder 

• Family history of suicide 

• Family violence, including physical or sexual abuse 

• Prior suicide attempt 

• Firearm in the home 

• Incarceration 

• Exposure to the suicidal behavior of others, including family, peers, or in the news or fiction stories 

How to help
It is not true that if a person talks about suicide, they will not attempt it. Seriously suicidal people make such comments for a variety of reasons--it is extremely important to take these remarks seriously and help that person seek a mental health evaluation and treatment. A person in crisis may not be aware that they are in need of help or be able to seek it on their own. They may also need to be reminded that effective treatment for depression is available, and that many people can very quickly begin to experience relief from depressive symptoms. 

Prevention Programs
Studies have shown that the suicide prevention programs most likely to succeed are those with a broader focus on identification and treatment of mental illness and substance abuse, coping with stress, and controlling aggressive behaviors. All suicide prevention programs first need to be tested for efficacy and safety. 

In Harm's Way: Suicide in America
Suicide is a serious public health problem. This fact sheet discusses risk factors that may lead to suicide, the differences between men and women in their suicidal behavior, and the facts regarding the increase rate of suicide among young people. Scientific research data on attempted suicide, and information on the components of a successful suicide prevention program, are presented. 

Older Adults: Depression and Suicide Facts
An unrecognized and untreated medical illness, major depression is a significant predictor of suicide in elderly Americans, with individuals age 65 and older accounting for 20 percent of all suicide deaths. This fact sheet presents current research and treatment options for the elderly population, and includes a cue card to help patients and doctors recognize the symptoms of depression in older adults

This information is available courtesy of the NIMH.  It is in the public domain and can be downloaded, reproduced, or copied without permission. For more information go to http://www.nimh.nih.gov/practitioners/patinfo.cfm

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