Depression Overview

Everyone gets “the blues” when disappointed. And everyone gets depressed over job lay-offs, divorce, the death of a loved one, or other major losses. Sadness is a normal part of life. But when sadness never returns to gladness, it becomes what the National Institute of Mental Health (NIMH) calls the nation’s leading mental health problem, “clinical” or “major” depression.

Depression is so common, it’s often called “the common cold of mental illness.” In any year, 10 percent of Americans—some 17 million people—suffer episodes of major depression. Depression can strike at any age, though symptoms in children, teens, and the elderly are often unusual (see below).

Depression costs the nation more than $43 billion a year for medications, professional care, and lost school and work days. The toll in human misery is incalculable. The dark cloud of depression has an even darker lining—thoughts of suicide. Each year, tens of thousands of depressed people attempt suicide. About 30,000 succeed, making suicide the nation’s ninth leading cause of death.

Even when depression doesn’t lead to suicide, it shortens life. University of Pittsburgh researchers assessed depression in 5,201 elderly people, and then followed them for five years. Independent of all other factors (age, illness, education, marital status, etc.), those who were initially depressed had a death rate 38 percent higher. Danish researchers came up with similar findings. They surveyed the physical and mental health of 730 men and women in the Danish town of Glostrup over 27 years beginning in 1964. Compared with participants who were not depressed, those who were had a death rate 60 percent higher. Why does depression lead to an early grave? Largely because it impairs the immune system, notably by suppressing the activity of natural killer cells, special white blood cells that fight disease.

Many famous people have struggled with clinical depression, among them: President Abraham Lincoln, former talk show host Dick Cavett, journalist Mike Wallace, poet Sylvia Plath, statesman Winston Churchill, artist Georgia O’Keefe, actor Rod Steiger, and writers William Styron, Virginia Woolf, Ernest Hemingway, William Faulkner, and Mark Twain.

The American Psychiatric Association recognizes several types of clinical depression:

• Normal Grief: Grief is a natural reaction to loss. Triggered by a specific event, it involves sadness, lethargy, and in serious cases, for example, grief after the death of a loved one, often despair, anger, insomnia, poor appetite, or weight gain, obsessive thoughts about the departed one, and possibly guilt about problems in your relationship with the person. But eventually, you recover. After losing a job you wanted, it may take a week or two to bounce back. After a lay-off, it may take a few months. After the death of a loved one, it may take a year. But if you never become your old self again, you may have clinical depression and should consult a doctor.

• Adjustment Disorder with Depressed Mood. Life is full of changes. Coping with them can be difficult. You may feel overwhelmed and “crazy” for a while. Then you get things under control. If you don’t, and become persistently gloomy, angry, and unable to cope, that’s adjustment disorder with depressed mood.

• Mild Depression (Dysthymia). This causes loss of self-esteem and low-level symptoms of major depression (see below). You become a “sad sack” and feel like a loser. Quite often, dysthymia (dis-THIME-ee-uh) has no specific trigger, no loss or life change. But just as you can catch a cold seemingly out of nowhere, you can also slip into dysthymia for no apparent reason.

• Major Depression. This is what people mean when they call someone “seriously depressed.” Major depression often causes despair and hopelessness so profound that you lose interest in life, become incapable of feeling pleasure and sexual arousal, and may be unable to get out of bed or eat for days at a time. But this illness may also cause other symptoms not popularly associated with depression: anxiety, irritability, agitation, chronic indecisiveness, weigh loss or gain, or sleep disturbances (insomnia or sleeping all the time). In other words, you can suffer major depression and not feel very blue. Quite often, major depression strikes without any triggering loss.

Beyond the misery it causes, the big risk with major depression is suicide. Within five years of suffering major depression, up to 25 percent of those with major depression try to kill themselves.

• Bipolar Disorder (Manic-Depression): This illness involves alternating periods of major depressive and unusually high energy (mania). Mild mania (hypomania) involves cheerfulness to the point of excessive self-confidence. Moderate mania combines grandiose ideas with agitation, irritability, paranoia, or anger. Severe mania causes greater agitation and hyperactivity. However, these brief descriptions do not do mania justice. Its manifestations are as unique as the individuals who become bipolar. Mania is not always negative. Manic individuals may be amazingly productive. Typically, bipolar disorder develops without any clear cause.

• Atypical Depression: “Atypical” means unusual. Instead of feeling unrelenting gloominess and lethargy, a person with this condition might seem deeply depressed for a few days, then fine for a while, or anxious and irritable. Like many other forms of depression, the atypical variety often develops without a triggering event.

• Seasonal Affective Disorder (SAD): Often called “winter blues,” this is a reaction to lack of sunlight in winter (see sidebar).

• Post-Partum Depression. New mothers typically expect to feel overjoyed. But because of the enormous hormonal changes of delivery and the challenges of dealing with an infant, some two-thirds of women feel transient sadness. About 10 to 15 percent become clinically depressed. And about 1 in 1,000 become so severely depressed that they must be hospitalized for their own safety and the safety of the baby (see sidebar).

The various types of depression don’t have clear boundaries, says psychiatrist Alan Brauer, M.D., founder of TotalCare Medical Center in Palo Alto, California, one of the nation’s first clinics to combine mainstream and complementary therapies. It takes professional judgment to know when normal grief or an adjustment disorder cross the line to become the more serious forms of depression. Friends and relatives often miss the subtle signs that point to a need for professional help. Many doctors also have difficulty diagnosing depression, often because people don’t mention depressive symptoms. Psychiatrist William Zung, M.D., and colleagues at Duke University Medical Center in Durham, North Carolina, and elsewhere, surveyed 75,858 people who visited primary care physicians. Only 1 percent complained of depression, but 21 percent had at least some depressive symptoms. No wonder depression often goes undetected, and so many people attempt suicide.

Depression may be difficult to diagnose, but it has clear biochemical roots, Dr. Brauer explains. Depressed individuals have unusual levels of one hormone (cortisol) and several brain chemicals (the neurotransmitters: serotonin, dopamine, and norepinephrine). These biochemical abnormalites can be inherited, which one reason why depression tends to run in families. Another is that children of depressed parents pick up their gloomy worldview.

No one knows exactly what triggers the biochemical changes that cause depression, says Stuart Yudofsky, M.D., of the psychiatry department at Baylor College of Medicine in Houston, but several important risk factors have been identified:

• Previous depression. Depression tends to recurr. In Seattle, University of Washington researchers followed 251 people previously treated for major depression. Within one year of their diagnosis, 37 percent suffered another bout of major depression. The more episodes, the greater the risk of recurrence.

• Family history. An estimated 20 percent of people who suffer depression have close relatives who have also had it. If you have a close family member who has suffered major depression, you’re at increased risk. Some of this risk appears to be genetic, the rest, the result of your family environment.

• Severely stressful events. For those predisposed to depression by heredity or upbringing, severe stress may trigger it, for example, job loos or death of a loved one. Depression may not develop immediately, but may take six months to a year.

• Drug abuse. Alcohol, a central nervous system depressant, is the major offender, especially in men. (see below). But several other drugs can trigger or aggravate depression, among them: Valium and other tranquilizers, birth control pills, the flu medicine amantadine (Symmetrel), steroids (prednisone, cortisone), and some cancer chemotherapy drugs.

• Women: According to most surveys, women suffer depression twice as frequently as men, recover from it more slowly, and are more likely to suffer recurrences. One reason is that women must cope with the mood-altering hormonal effects of the menstrual cycle, pregnancy, childbirth, infertility, and/or oral contraceptives.

Another is that compared with men, women have traditionally been socialized into more passive social roles, which may leave them feeling powerless, and prone to depression. Recent social changes have made the sexes more equal, but some women are still brought up to be subservient, and even when they are not, some women have found it difficult—and possibly depressing—to adjust to the recent changes in their position in society.

“Women are also more likely than men to define themselves in terms of their relationships with others,” says Boston-area psychologist Eda Spielman, Psy.D., who teaches at the Massachusetts School of Professional Psychology. “As a result, women tend to experience losses more deeply, which makes them more vulnerable to depression.”

Finally, some research suggests that severe childhood emotional trauma often plays a role. The American Psychological Association’s Task Force on Women and Depression discovered that 37 percent of depressed women had suffered significant physical or sexual abuse by age 21.

On the other hand, compared with women who have no children, mothers are much less likely to suffer severe depression or attempt suicide, presumably because the intensity of their relationships with their children shields them against emotional damage from other losses.

• Men. Men are less likely than women to suffer the classic symptoms of depression. But Terrence Real, Ph.D., a psychotherapist in Cambridge, Massachusetts who specializes in depression in men, contends that they are just as likely to get depressed. However, they reveal it differently, through alcoholism, other substance abuse, and antisocial behavior.

• Children and Teens. It can be hard to spot depression in young people for two reasons: Even when not depressed, they often experience frequent, roller-coaster mood swings. In addition, depression in kids and teens may not cause classic symptoms of depression. Instead, you might notice irritability, angry outbursts, and problems in school. Tragically, suicide is the third leading cause of death among Americans to age 24, taking more than 5,000 lives each year.

• The elderly. An estimated 15 percent of people over 65 experience depression at some point during their elderly years. Instead of typical symptoms, depressed elderly may complain of persistent fatigue, appetite loss, weight loss, and difficulty concentrating. Compared with other age groups, the elderly commit suicide twice as frequently. Suicides are especially common among elderly men, who account for 81 percent of suicides of those over 65.

• People with chronic illnesses. Depression is one of the most common—and potentially dangerous—complications of every chronic illness. Many surveys show how depressing it is to have a chronic illness. In the general population, the lifetime risk of depression is 10 to 20 percent for women and 5 to 12 percent for men. However, the prevalence of depression in those with chronic illnesses is much higher. NIMH studies show that depression develops in 25 percent of people with cancer or stroke, and about half of those with heart attacks. According to depression specialist Arthur Rifkin, M.D., a psychiatrist at Albert Einstein Medical Center in New York, the most common misconception about depression and chronic illness is that it’s understandable in the face of chronic illness. Perhaps, but only during the initial adjustment, a period that should last no longer than a few months. If depression lasts longer without treatment, it shortens life 11 percent, according to a study of 3,529 people with serious illnesses by researchers at Case Western Reserve University School of Medicine in Cleveland.

• Anyone Born After You Were: For reasons that remain unclear, rates of clinical depression have increased worldwide in each succeeding generation born since 1915. The fact is, anyone can become seriously depressed. That’s why everyone should know more about it.

Tragically, only two-thirds of those suffering what William Shakespeare called “too much sadness,” and author and depression survivor William Styron has called “despair beyond despair” ever seek treatment. The myth is that people who can’t “pull themselves up by their bootstraps” lack character. But “depression is not a moral weakness,” says psychiatrist Alan Brauer, M.D., founder of TotalCare Medical Center in Palo Alto, California, one of the nation’s first clinics to combine mainstream and complementary therapies. “It’s a medical illness with clear biological roots.”

Fortunately, depression is increasingly treatable—with a number of nondrug and complementary therapies in addition to pharmaceutical antidepressants. With the combination of therapies now available, “as many as 85 percent of people with major depression have fairly good results,” says John McIntyre, M.D., a past president of the American Psychiatric Association (APA). Even if you take an antidepressant, Dr. Brauer says you usually get better results by combining drugs with nondrug and complementary approaches.