Clinical Depression

About 5%-10% of women and 2%-5% of men will experience at least one major depressive episode during their adult life.

Throughout the course of our lives, we all experience episodes of stress, unhappiness, sadness, or grief. Often, when a loved one dies or we suffer a personal tragedy or difficulty such as divorce or loss of a job, we may feel depressed (some people call this "the blues"). Most of us are able to cope with these and other types of stressful events.

Over a period of days or weeks, the majority of us are able to return to our normal activities. But when these feelings of sadness and other symptoms make it hard for us to get through the day, and when the symptoms last for more than a couple of weeks in a row, we may have what is called "clinical depression." The term clinical depression is usually used to distinguish the illness of depression from less difficult feelings of sadness, gloom, or the blues.

Clinical depression is not just grief or feeling sad. It is an illness that can challenge your ability to perform even routine daily activities. At its worst, depression may lead you to contemplate, attempt, or commit suicide. Depression represents a burden for both you and your family. Sometimes that burden can seem overwhelming.

There are several different types of clinical depression (mood disorders that include depressive symptoms):

• Major depression is an episode of change in mood that lasts for weeks or months. It is one of the most severe types of depression. It usually involves a low or irritable mood and/or a loss of interest or pleasure in usual activities. It interferes with one's normal functioning and often includes physical symptoms. A person may experience only one episode of major depressive disorder, but often there are repeated episodes over an individual's lifetime.
• Dysthymia, often commonly called melancholy, is less severe than major depression but usually goes on for a longer period, often several years. There are usually periods of feeling fairly normal between episodes of low mood. The symptoms usually do not completely disrupt one's normal activities.
• Bipolar disorder involves episodes of depression, usually severe, alternating with episodes of extreme elation or irritability called mania. This condition is sometimes called by its older name, manic depressive disorder. The depression that is associated with bipolar disorder is often referred to as a bipolar depression. When depression is not associated with bipolar disorder, it is called unipolar depression.
• Seasonal depression, which medical professionals call seasonal affective disorder or SAD, is depression that occurs only at a certain time of the year, usually, winter when the number of daylight hours is lower. It is sometimes called "winter blues." Although it is predictable, it can be very severe.
• Psychotic depression refers to the situation when depression might lead to developing psychosis: hallucinations or delusions. This may be the result of depression that becomes so severe that it results in the sufferer losing touch with reality. Individuals who primarily suffer from a loss of touch with reality (for example, schizophrenia) are thought to suffer from an imbalance of dopamine activity in the brain and to be at risk of subsequently becoming depressed.

Adjustment disorder is a state of distress that occurs in relation to a stressful life event. It is usually an isolated reaction that resolves when the stress passes. Although it may be accompanied by a depressed mood, it is not considered a depressive disorder.

Some people believe that depression is "normal" in people who are elderly, have other health problems, have setbacks or other tragedies, or have bad life situations. On the contrary, clinical depression is always abnormal and always requires attention from a medical or mental health professional. The good news is that depression can be diagnosed and treated effectively in most people. The biggest barriers to overcoming depression are recognition of the condition and seeking appropriate treatment.

Depression Statistics

About 5%-10% of women and 2%-5% of men will experience at least one major depressive episode during their adult life. Depression affects people of both genders, as well as all races, incomes, ages, and ethnic and religious backgrounds. However, it is twice as common in women compared to men and three to five times more common in the elderly than in young people.

Clinical depression is not something you feel for a day or two before feeling better. In true depressive illnesses, the symptoms last weeks, months, or sometimes years if you don't seek treatment. If you are depressed, you are often unable to perform daily activities. You may not care enough to get out of bed or get dressed, much less work, do errands, or socialize.

• Adults: You may be said to be suffering from a major depressive episode if you have a depressed mood for at least 2 weeks and have at least 5 of the following clinical symptoms:
  • Feeling sad or blue
  • Crying spells
  • Loss of interest or pleasure in usual activities
  • Significant increase or decrease in appetite
  • Significant weight loss or weight gain
  • Change in sleep pattern: inability to sleep or excessive sleeping
  • Agitation or irritability
  • Fatigue or loss of energy
  • A tendency to isolate from friends and family
  • Trouble concentrating
  • Feelings of worthlessness or excessive guilt
  • Thoughts of death or suicide

Men and women sometimes show depression differently. Specifically, men are more likely to experience irritability, sleep problems, fatigue, and loss of interest in activities they liked previously as a result of depression whereas women tend to have overt sadness and feelings of worthlessness and guilt when depressed. For people who tend to suffer from an increase in appetite, tiredness, and the tendency to sleep (atypical depression), carbohydrate craving, sometimes specifically for chocolate, may occur. That has been found to sometimes be an indication that the person tends to suffer from irritability and anxiety in addition to depression.

• Children with depression may also experience the classic symptoms but may exhibit other symptoms as well, including the following:
  • Poor school performance
  • Persistent boredom
  • Frequent complaints of physical symptoms, such as headaches and stomachaches
  • Some of the classic adult symptoms of depression may also be more obvious in children, such as changes in eating or sleeping patterns (Has the child lost or gained weight in recent weeks or months? Does he or she seem more tired than usual?)
  • Symptoms and signs of depression in teens may include more risk-taking behaviors and/or showing less concern for their own safety. Examples of risk-taking behaviors include driving recklessly/at excessive speed, becoming intoxicated with alcohol or other drugs, especially in situations in which they are driving or may be in the presence of others who engage in risky behaviors, and engaging in promiscuous or unprotected sex.

• Parents of children with depression report noticing the following behavior changes. If you notice any of these, discuss this with your health care provider.
  • The child cries more often or more easily.
  • The child's eating habits, sleeping habits, or weight change significantly.
  • The child has unexplained physical complaints (for example, headaches or abdominal pain).
  • The child spends more time alone, away from friends and family.
  • The child actually becomes more "clingy" and may become more dependent on certain relationships. This is less common than social withdrawal though.
  • The child seems to be overly pessimistic or exhibits excessive guilt or feelings of worthlessness.
  • The child expresses thoughts about hurting him or herself or exhibits reckless or other harmful behavior.

• Elderly: While any of the classic symptoms and signs of depression may occur in elderly men and women, other symptoms also may be noted:
  • Diminished ability to think or concentrate
  • Unexplained physical complaints (for example, abdominal pain, changes in bowel habits, or muscle aches)
  • Memory impairment (occurs in about 10% of those with severe depression)

Since symptoms of depression tend to be more physical in elderly individuals compared to younger individuals, this puts these individuals at risk for having their depressive symptoms erroneously attributed to medical problems.

The causes of depression are complex. Genetic, biological, and environmental factors can contribute to its development. In some people, depression can be traced to a single cause, while in others, a number of causes are at play. For many, the causes are never known. Currently, it appears that there are biochemical causes for depression, occurring as a result of abnormalities in the levels of certain chemicals in the brain. These chemicals are called neurotransmitters.

The abnormalities are thought to be biological and are not caused by anything you do or have done in the past. While we still don't know exactly how levels of these neurotransmitters affect mood, we do know that the levels can be affected by a number of factors.

• Heredity: Certain types of depression seem to run in some families. Research is ongoing as to exactly which genes are involved in depression. Just because someone in your family has depression, however, doesn't mean you will. Sometimes, family members who were known to abuse alcohol or other drugs were unwittingly trying to improve their mood (often called "self-medication" by professionals). Likewise, you can become depressed even if no one else in your family is known to have depression.
• Personality: People with certain personality traits are more likely to become depressed. These include negative thinking, pessimism, excess worry, low self-esteem, a hypersensitivity to perceived rejection, overdependence on others, a sense of superiority or alienation from others, and ineffective responses to stress.
• Events: Difficult life events, loss, change, or persistent stress can cause levels of neurotransmitters to become unbalanced, leading to depression. Even events that tend to be major happy occasions, such as pregnancy and childbirth, can cause changes in hormone levels, be stressful and cause clinical depression, as in postpartum depression.
• Medical conditions: Depression is more likely to occur with certain medical illnesses. These "co-occurring" conditions include heart disease, stroke, diabetes, cancer, hormonal disorders (especially perimenopause or hypothyroidism, known as "low thyroid"), Parkinson's disease, and Alzheimer's disease. While it does not appear that allergies cause depression or vice versa, people who suffer from nonfood allergies have been found to be somewhat more vulnerable to also having depression compared to people who do not have allergies. Clinical depression should not be considered a normal or natural reaction to illness.
• Medications: Some medications used for long periods, such as prednisone, certain blood pressure medicines, sleeping pills, antibiotics and even birth control pills in some cases, can cause depression or make an existing depression worse. Some antiseizure medications, like lamotrigine (Lamictal), topiramate (Topamax), and gabapentin (Neurontin), may be associated with a higher risk of suicide.
• Substance abuse: While it has long been believed that depression caused people to misuse alcohol and drugs in an attempt to make themselves feel better (self-medication), it is now thought that the reverse can also be the case; substance abuse can actually cause depression.
• Diet: Deficiencies in certain vitamins, such as folic acid and B-12, may cause depression.

Certain people are more likely to develop clinical depression. The following are risk factors for depression in adults include:

• female gender
• advanced age
• lower socioeconomic status
• recent stressful life experience
• chronic (long-term) medical condition
• underlying emotional or personality disorder
• substance abuse (such as alcohol, sleeping medications
• medications for panic or anxiety, or cocaine)
• family history of depression, especially in a close relative (such as a parent, brother or sister, or child)
• lack of social support

Many of these risk factors also apply to children. Other risk factors for childhood or teenage depression include:

• continual mental or emotional stress at home or at school
• presence of any medical condition, even as mild as acne
• a recent loss
• attention problems (ADHD)
• learning or conduct disorder
• obesity

Risk factors for depression in elderly people include those listed for adults:

• Co-occurring illnesses become much more important risk factors in the elderly because of the higher incidence of these illnesses in older people. Diseases that may be accompanied by depression include:
  • heart disease
  • stroke
  • diabetes
  • cancer
  • thyroid disease
  • Parkinson's disease
  • Alzheimer's disease
• Depression is a side effect of some medications in the elderly. Not taking medication for certain conditions may also cause depression.
• Other examples of risk factors for depression in the elderly include:
  • living alone
  • social isolation
  • being recently widowed

Many health care providers can help diagnose clinical depression: licensed mental-health therapists, family physicians, or other primary care providers, specialists whom you see for a medical condition, emergency physicians, psychiatrists, psychologists, psychiatric nurses, and social workers.

If one of these professionals suspects that you have depression, you will undergo an extensive medical interview and physical examination. As part of this examination, you may be asked a series of questions from a standardized questionnaire or self-test to help assess your risk of depression and suicide.

Depression may be associated with a number of other medical conditions or can be a side effect of various medications. For this reason, routine laboratory tests are often performed during the initial evaluation to rule out other causes of your symptoms. Occasionally, an X-ray, scan, or another imaging study may be needed.

If your symptoms indicate that you have clinical depression, your health-care provider will strongly recommend treatment. Treatment may include addressing any medical conditions that cause or worsen depression. For example, an individual who is found to have low levels of thyroid hormone might receive thyroid hormone replacement with levothyroxine (Synthroid, Levoxyl).

Other components of treatment include supportive therapy, such as changes in lifestyle and behavior, psychotherapy, complementary therapies, and may often include medication. If your symptoms of depression are severe enough to warrant treatment with medication, you are most likely to feel better faster and for longer when medication treatment is combined with psychotherapy.

Most practitioners will continue treatment of major depression for 6 months to a year. Treatment for teens with depression can have a significantly positive effect on the adolescent's functioning with peers, family, and at school. Without treatment, your symptoms will last much longer and may never get better. In fact, they may get worse. With treatment, your chances of recovery are quite good.

Therapy frequently includes antidepressant medication and supportive care such as psychotherapy. Other less widely used therapies, such as electroconvulsive therapy, are used in severe cases.

Therapy may be provided by your health-care provider or by a specially trained mental health professional. Psychiatrists are medical doctors who have completed specialized training in mental disorders. Psychologists are nonphysicians who have graduate (after college) and doctorate-level (Ph.D.) training that includes experience in mental-health-care facilities. Psychotherapists may have a degree in medicine (psychiatry), psychology, social work, nursing, mental health counseling, or couples and family therapy, as well as adding more specialized education or training.

Regardless of which treatment is used, psychotherapy, medication, or a combination, most people with depression can safely be treated in a series of office (outpatient) visits. Inpatient care (in the hospital) may be necessary for people with more serious symptoms and is required for those who are contemplating suicide or cannot care for themselves.

The major types of antidepressant medication are the selective serotonin reuptake inhibitors (SSRIs), the tricyclic antidepressants (TCAs), the monoamine oxidase inhibitors (MAOIs), and the atypical antidepressants.

SSRI medications affect levels of serotonin in the brain. For many prescribing doctors, these medications are the first choice because of the high level of effectiveness and general safety of this group of medicines. Examples of these medications are listed here. The generic name is first, with the brand name in parentheses. These drugs are best known by their brand names. Examples of SSRIs are:

• fluoxetine (Prozac)
• sertraline (Zoloft)
• paroxetine (Paxil)
• fluvoxamine (Luvox)
• citalopram (Celexa)
• escitalopram (Lexapro)

TCAs are sometimes prescribed in severe cases of depression or when SSRI medications don't work. These medications affect a number of brain chemicals (neurotransmitters), especially epinephrine and norepinephrine (also called adrenaline and noradrenaline, respectively). Interestingly, premenopausal women tend to improve more and have fewer side effects when treated with SSRIs versus TCAs, while men tend to do better when their depression is treated with a TCA. Like the SSRIs, most of these are better known by their brand names. Examples include:

• amitriptyline (Elavil)
• clomipramine (Anafranil)
• desipramine (Norpramin)
• doxepin (Adapin)
• imipramine (Tofranil)
• nortriptyline (Pamelor)

Atypical neuroleptic medications are increasingly being prescribed in addition to an antidepressant in people with unipolar depression who do not improve after receiving trials of different antidepressants and in addition to, or instead of, an antidepressant in people who suffer from bipolar disorder. Although clozapine (Clozaril) is often considered to be the first discovered atypical neuroleptic, the risk it carries for severe anemia and decrease in bone-marrow functioning generally disqualifies its use in depressed patients. Examples of other atypical neuroleptics include:

• aripiprazole (Abilify)
• olanzapine (Zyprexa)
• paliperidone (Invega)
• quetiapine (Seroquel)
• risperidone (Risperdal)
• ziprasidone (Geodon)
• asenapine (Saphris)
• iloperidone (Fanapt)

Non-neuroleptic mood-stabilizer medications are also sometimes used with an antidepressant to treat people with unipolar depression who do not improve after receiving trials of different antidepressants and in addition to or instead of an antidepressant in those who suffer from bipolar disorder. Examples of non-neuroleptic mood stabilizers include:

• lithium (Lithium Carbonate, Lithium Citrate)
• divalproex sodium (Depakote)
• carbamazepine (Tegretol)
• lamotrigine (Lamictal)

Of the non-neuroleptic mood stabilizers, Lamictal seems to be unique in its ability to also treat unipolar depression effectively by itself as well as in addition to an antidepressant.

The MAOIs are not used as often since the introduction of the SSRIs. Because of interactions with some anti-depression medications and specific foods, the MAOIs may not be taken with many other types of medication and some types of foods that are high in tyramine (like aged cheeses, wines, and cured meats) must be avoided as well. Examples of MAOIs include:

• phenelzine (Nardil)
• tranylcypromine (Parnate)

Another group of antidepressants works similarly to the commonly used SSRIs, affecting additional neurotransmitters, like dopamine and norepinephrine. They include:

• bupropion (Wellbutrin)
• mirtazapine (Remeron)
• trazodone (Desyrel)
• venlafaxine (Effexor)
• duloxetine (Cymbalta)
• desvenlafaxine (Pristiq)

One-half to two-thirds of people who take antidepressant medications get better. It may take anywhere from one to six weeks of taking medication at its effective dose to start feeling better. Don't give up taking the medication if you don't feel better right away. Your doctor will see you again during this period to see if your body is tolerating the medication and if your symptoms are better. If they are not, he or she may adjust your dose or prescribe a different medication.

Even after you feel better, you should continue to take the medication for six to nine months. Stopping the medication too soon may cause your symptoms to return or to get worse. Some people need to take the medication for longer periods of time to keep the depression from returning.

Do not stop taking the medication without talking to your doctor because stopping abruptly may cause serious withdrawal effects. If you and your doctor agree that it is time to stop the medication, the dose usually will be slowly tapered to prevent these effects.

The side effects of antidepressant medications vary considerably from drug to drug and from person to person.

• Common side effects include dry mouth, sexual dysfunction, nausea, tremor, insomnia, blurred vision, constipation, and dizziness.
• You may need to follow some dietary restrictions if you are taking MAOI medications.
• In very rare cases, some patients have been thought to have become acutely more depressed once on the medication, even attempting or completing suicide or homicide. Children and teenagers are thought to be particularly vulnerable to this rare possibility. However, when considering this risk, it is important to also consider the risk of the potentially serious outcomes that can result from untreated depression.
• If antidepressant medication is prescribed for you, ask your health-care provider what kind of side effects you can expect.

Psychotherapy ("talk therapy")

This involves working with a trained therapist to figure out ways to solve problems and cope with depression. It can be a powerful intervention, even producing positive biochemical changes in the brain. Three major approaches are commonly used to treat clinical depression. In general, these therapies take weeks to months to complete. Each has a goal of alleviating your symptoms. More intense psychotherapy may be needed for longer when treating very severe depression or for depression with other psychiatric symptoms.

Interpersonal therapy (IPT)

This helps to alleviate depressive symptoms and helps you develop more effective skills for coping with social and interpersonal relationships. IPT employs two strategies to achieve these goals. The first is education about the nature of depression. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment. The second is defining your problems (such as abnormal grief or interpersonal conflicts). After the problems are defined, the therapist is able to help set realistic goals for solving these problems. Together you will use various treatment techniques to reach these goals.

Cognitive behavioral therapy (CBT)

This helps to alleviate depression and reduce the likelihood it will come back by helping you change your way of thinking. In CBT, the therapist uses three techniques to accomplish these goals. 1. Didactic component. In this phase helps to set up positive expectations for therapy and promote your cooperation. 2. Cognitive component: This helps to identify the thoughts and assumptions that influence your behaviors, particularly those that may predispose you to being depressed. 3. Behavioral component: This employs behavior-modification techniques to teach you more effective strategies for dealing with problems.

Behavioral therapy (BT)

This helps to modify your depressive behaviors through highly structured, goal-oriented therapy. BT uses three techniques to accomplish these goals. Functional analysis of behavior: This helps to define the behaviors that will be targeted for change. Selection of specific techniques: Various techniques can be employed to help modify the selected behavior, including relaxation training, assertiveness training, role-playing, and time-management tips.

Monitoring behavior

Progress and program effectiveness can be monitored by logs and records you keep.

Alternative treatments

Several nonprescription herbal and dietary supplements are used by some people to treat depression. Little is known about the safety, effectiveness, or appropriate dosage of these remedies, although they are taken by thousands of people around the world.

• A few of the best-known alternative remedies continue to be studied scientifically to see how well they work, but to date, there is little evidence that herbal remedies effectively treat moderate to severe clinical depression.
• Medical professionals usually are hesitant to recommend herbs or dietary supplements because they are not regulated by the U.S. Food and Drug Administration (FDA), as prescription drugs are, to ensure their purity and quality. Regardless, if you are on any medication, dietary supplement, or other remedy, be sure to check with your health-care provider before starting an herbal or dietary supplement.
• When you buy a supplement from the drugstore or health-food store, you cannot be sure exactly what you are getting and what is the appropriate dosage.
• There are few guidelines for correct doses. Potency can vary from product to product, even batch to batch of the same product.

St. John's wort: This is probably the best-known alternative therapy for depression. It is derived from a plant, Hypericum perforatum, and has been part of folk medicine for centuries.

• It has been widely used in North America and Europe to treat anxiety, depression that is of mild severity, and sleep disorders.
• It is available in pill form, like capsules, tablets, as a liquid extract, and in various teas.

Studies conducted in Europe suggested that St. John's wort works as well as prescription antidepressants with fewer side effects. In other more recent studies sponsored and well designed by the National Institutes of Health, St. John's wort worked no better than a sugar pill (placebo) in relieving depression.

St. John's wort is not without its own negative effects.

• One problem with St. John's wort is that it interacts with many other medications. Some of these interactions can be dangerous.
• It also may make other medications stop working, including some that are used to treat cancer or HIV infection or to prevent organ rejection after transplant.
• If taken with an SSRI drug, St John's wort can cause a potentially dangerous condition called serotonin syndrome. The combination is not recommended.
• Common side effects include dry mouth, dizziness, digestive symptoms, fatigue, and increased sensitivity to sunlight. It is not recommended for people with seasonal depression using bright light therapy.

SAM-e: The chemical name of this agent is S-adenosyl-methionine. It occurs naturally in the body and has many functions.

• Some believe that it increases neurotransmitter levels in the brain, but this has not been proven.
• In Europe, it is a prescription drug.
• In the United States, it is available without prescription and is sold as a dietary supplement, although it is quite expensive.
• Its effectiveness in depression is unknown.
• It has few side effects.

5-HTP: This agent, 5-hydroxytryptophan, is another substance that occurs naturally in the body, where it is used to make serotonin. Although there is some evidence that this agent relieves depression with fewer side effects than SSRIs, the evidence is by no means conclusive.

Omega-3 fatty acids: Deficiencies in these natural substances have been linked to depression, especially bipolar disorder. They are found in certain plants and fish oil. Fish-oil capsules are available at natural-food stores, but they have digestive side effects in many people. By far the best source is fish, especially oily fish such as salmon and mackerel. These fatty acids also promote a healthy heart and blood vessels.

Complementary therapies

Many different complementary therapies are advocated by different groups and individuals to assist in dealing with depression. These include the following:

• Lifestyle changes such as adopting a healthy diet, exercise, and stress reduction
• Meditation, biofeedback, and other relaxation therapies
• Hypnosis to help the individual focus their attention more constructively may be a helpful addition to the treatment of depression
• Physical therapies such as massage, reflexology, and acupuncture
• Environmental therapies such as aromatherapy and music therapy
• Spiritual or faith-based activities
• Interactions with other people and animals
• Limiting alcohol intake and refraining from using illicit drugs or abusing prescription drugs altogether

Most of these are safe for all or most people and may contribute to your overall well-being.

• They are not, however, a replacement for medical therapy known to be effective in most people.
• Check with your health-care provider, especially if you are taking antidepressant medication, before starting any new diet or exercise program, new medications, or herbal preparations or supplements.

Electroconvulsive therapy

Electroconvulsive (ECT) or shock therapy is safe and effective on a short-term basis as an alternative for people with very severe clinical depression who have not improved with a number of other treatments or in people who cannot safely take antidepressant medication. It involves the induction of seizures in a controlled medical setting by a trained health-care practitioner in a patient who is appropriately sedated. Although there has been much controversy about ECT, much of this debate has been caused by impressions of ECT when it was fairly new (its use was begun in 1939) and not as sophisticated or specifically done as it is today. ECT has been shown to alter the levels of brain neurotransmitters that may cause depression.

• ECT is often reserved for those with severe symptoms that do not respond to medications or for people who are suicidal.
• Elderly people who cannot tolerate the side effects of antidepressant medications are sometimes good candidates for ECT. Specifically, elderly individuals have been found to tolerate and benefit from ECT as well as younger adults.
• Prior to undergoing ECT, you would have a complete medical evaluation. Typically, you are sedated and cannot remember the ECT procedure itself.
• Commonly, you might have a brief period of confusion after the procedure. You may feel muscle aches or a headache after treatment. Some memory loss, usually quite temporary, is fairly common with ECT as well. Those who receive 12 or more ECT treatments may experience more long-lasting memory and learning problems.
• ECT treatments are generally given every other day for two to three weeks (for about six to 10 treatments). The actual duration of therapy depends on your response to it. Some people need to follow up with regularly scheduled "booster treatments," or so-called "maintenance ECT," after improving with this treatment. Over the longer term, the effects of ECT may fade.

People who have risk factors for depression should be "screened" regularly by their health-care provider. This means that when they see their health-care provider, questions should be asked that might indicate depression.

If identified early, those who are at risk for depression are more likely to benefit from treatment.

Untreated episodes of clinical depression typically last from 6-24 months.

When properly treated, episodes resolve in much shorter time periods. 

• About two-thirds of people will recover and be able to return to their normal activities within days or weeks.
• About 25% of people will continue to exhibit moderate to severe symptoms for months to years after the initial episode.
• Nearly 10% of people with depression will have continuous or intermittent symptoms for 2 or more years. A person who has one episode of depression should be on the lookout for recurrent episodes of depression, since these occur about 50% of the time. However, timely treatment is usually effective for these recurrent episodes as well.

Once you are being treated for depression, you can make lifestyle changes and choices that are forms of self-help through the rough times and may prevent depression from returning.

• Try to identify and focus on activities that make you feel better. It is important to do things for yourself. Don't isolate yourself. Take part in activities even when you may not want to. Such activity may actually make you feel better.
• Talk with your friends and family and consider joining a support group. Communicating and discussing your feelings is an integral part of your treatment and will help with your recovery.
• Try to maintain a positive outlook. Having a good attitude can be beneficial.
• Regular exercise and proper diet are essential to good health. Exercise has been found to increase the levels of the body's own natural antidepressants called endorphins.
• Try to get enough rest and maintain a regular sleeping pattern.
• Avoid drinking alcohol or using any illicit substances.

If you feel that you are depressed, you may wish to talk about your feelings with a family member or a close friend. Communication is one of the keys to early diagnosis and treatment. People close to you may have felt you were depressed. With their encouragement, you should call your health care provider.

If you feel someone else is depressed, talk to them:

• You may notice a person showing the signs of depression mentioned under Symptoms. If you observe feelings of worthlessness, excessive guilt, hopelessness, or any warning signs that the individual is having suicidal thoughts, contact a health-care provider immediately.
• With mild or moderately severe symptoms of short duration (weeks), it may be reasonable to contact a health-care provider for an appointment.
• It is often helpful to accompany a family member or friend to the medical office and offer support as needed.
• If the person has severe symptoms, cannot care for himself or herself, or is threatening to harm himself or herself, seek immediate treatment in a hospital emergency department.

After you are diagnosed with depression, your health-care provider will usually want you to be in frequent contact. You (or your family) may need to contact your primary-care provider, psychiatrist, psychologist, or other mental-health professional if you

• Are experiencing any unexpected or serious medication side effects.
• Start any new medication.
• Develop additional symptoms of depression, particularly if those symptoms are severe or develop rapidly.
• Feel that you are having setbacks and your present therapy is ineffective.
• Continue to suffer from bouts of anxiety and depression.
• Have trouble coping with your feelings and are starting to feel as if you are losing control.

Although health-insurance restrictions have resulted in hospitalizations occurring less frequently than in years past, hospitalization may be necessary with severe depression. You may choose to come to the hospital for evaluation, or your family or friends may need to bring you to the hospital for evaluation if you:

• Have thoughts of hurting yourself.
• Have thoughts of hurting someone else.
• Are no longer able to care for yourself.
• Refuse to follow through with important treatment recommendations, such as taking your medication.

Depending on the severity of your depression, you will see your health care provider more frequently, perhaps as often as every week or every other week, for the first six to eight weeks after the initial diagnosis of depression.

Be sure to tell your health care provider about any medication side effects or urges to hurt yourself or others.

If you or someone you know is considering suicide, call 1-800-SUICIDE (1-800-784-2433).

Additional information about depression can be obtained from these organizations:

Depression and Bipolar Support Alliance
730 North Franklin Street, suite 501
Chicago, IL 60610-3526
1-800-826-3632 or 312-642-0049
Email: [email protected]
Web site: http://www.ndmda.org/

National Foundation for Depressive Illness
PO Box 2257
New York, NY 10116
1-800-239-1265 or 212-268-4260

National Institute of Mental Health
1-866-615-6464 or 301-443-4513
[email protected]

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314
1-800-969-NMHA (6642) or 703-684-7722

National Organization for Seasonal Affective Disorder (NOSAD)
PO Box 42490
Washington, D.C. 20015
1-800-789-2647

Postpartum Support International
927 North Kellog Avenue
Santa Barbara, CA 93111
805-967-7376

National Center for Complementary and Alternative Medicine, St. John's Wort and the Treatment of Depression

National Institute of Mental Health, Depression

National Mental Health Association