Major Depression

By Johns Hopkins Health InformationLast reviewed:December 2009.

Major Depression
* What is it?
* Symptoms
* What the doctor looks for
* What you can do
* Treatment
* When to seek treatment
* Prognosis

What is it?
There is a tendency today to use the word "depression" to describe the inevitable periods of sadness that each of us experiences from time to time. Indeed, for many during these periods, it is not always easy to discern where normal sorrow ends and clinical depression begins. Yet anyone who has ever experienced a major depression knows-at least after the depression has lifted-that what they feel is more than just persistent sadness.

Clinical depression is an illness characterized by a cluster of feelings, thoughts and behaviors that are strikingly different from a person's normal range of feelings and functioning. Caused by a complex interaction of biological, social and psychological factors, a major depressive disorder can make a person exquisitely sensitive to life circumstances, the least of which can throw him into total black despair.

During a major depression, a person becomes enveloped by feelings of sadness, emptiness and worthlessness. Like an impenetrable curtain descending, these feelings distort every thought and experience, rendering life meaningless and hopeless. Feelings of being deeply, continually deprived, insignificant, inadequate and guilt-ridden build on feelings of sadness. At the same time, a depressed person may feel chronically irritated, occasionally erupting in frustration and anger.

Although a major depression may be triggered by some life circumstance or event, the mood reaction seems greatly exaggerated. In all likelihood, depression has less to do with events that occur than with an individual's inherent vulnerability to the condition.

In some cases, a person may experience only a single episode of major depression during their lifetime. However, in most instances, clinical depression tends to recur periodically, reactively or cyclically. An untreated major depressive episode typically lasts about a year, but can last longer. About 10% of persons with the disorder develop a chronic illness that can wax and wane for much longer periods of time, sometimes even for decades.

Milder depressive states that are more long-lasting (at least two years or more) characterize what is called dysthymic disorder. For these individuals, certain life circumstances such as the end of a relationship, the loss of a job or going away to college might provoke a deeper depression and causes the more severe symptoms of major depression develop.

It has been suggested that this division of clinical depressions into major depressive disorder and dysthymia is not a clinically meaningful distinction and that a more useful way of classifying depressive illnesses is according to whether the symptoms tend to be episodic and recurring, or chronic.

For some people, there is a seasonal aspect to their depression. Typically affecting people in the fall or winter, seasonal affective disorder (SAD) is characterized by fatigue, carbohydrate craving, overeating and oversleeping. SAD is a form of depression that is more prevalent in northern parts of the country where the climatic extremes are greater. The exact cause of the disorder is not certain, but it may be related how the light-responsive pineal gland in the brain functions.

Symptoms
* An acute and persistent sense of despair, sadness and hopelessness that seems to have little correlation to life circumstances
* A lack of interest or pleasure in most activities
* Feelings of sluggishness, fatigue, lethargy or agitation
* Feelings of worthlessness, inadequacy and hopelessness
* Preoccupation with thoughts of suicide or death
* A change in appetite and/or weight
* Difficulties in sleeping or a tendency to oversleep
* Diminished ability to concentrate and make decisions
* Significant changes in working and social patterns
* Social withdrawal

What the doctor looks for
A sustained and pervasive change in mood. Loss of interest in normal pleasures of life: food, sex, friends, work, family, sports, hobbies; a family or personal history of depression or suicide attempts; a change in the way one feels about oneself; a pattern of negative, pessimistic, self-blaming or self-critical thinking; suicidal thoughts and behavior.

What you can do
During the time that you feel despondent, seek the emotional support of family and friends. For milder depressions of short duration, the support of loved ones may help you through. But in most cases you will not be able to fight depression on your own, and you should not try to. Like asthma or hypertension, depression is an illness and requires medical attention so that it can be managed effectively. If you are suffering from a depression, it is important that you seek professional help.

Treatment
Many cases of milder depression can be treated effectively through psychotherapy. Even short-term therapy can help you identify and correct negative thoughts and difficulties in communicating with and relating to others that may contribute to depression. When depression is triggered by seasonal change, light therapy, which extends exposure to bright light for measured periods of time, may work to relieve symptoms.

In cases of more severe depression, medication will be the main method of treatment. At the same time, psychotherapy is usually an important complement to medication. By restoring normal functioning in certain areas deep in the brain, psychotropic medication will lift the veil of sorrow. The most commonly prescribed antidepressant medications are the selective serotonin reuptake inhibitors fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram (Lexapro). Other antidepressant medications include the tricyclic antidepressants imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline (Elavil), desipramine hydrochloride (Norpramin), venlafaxine (Effexor), trazodone (Desyrel), nefazodone (Serzone) and bupropion (Wellbutrin). Despite the fact that general practitioners can prescribe these medications, in severe cases it is probably wisest to consult a psychiatrist or psychopharmacologist who is specially trained to evaluate and monitor the need for and use of antidepressant medication. A variety of medications, including drugs used to treat bipolar disorder, are often needed in complex cases.

For many reasons, antidepressants often take a few weeks to start working. Also, because every person as well as his depression differs, finding the most effective drug may require a trial of more than one medication. You and your doctor will eventually find the right treatment; an adequate trial of an antidepressant takes four to five weeks.

During a severe episode, there may be severe paranoid, persecutory delusions or even hallucinations. There may be suicidal thoughts. When these occur, hospitalization, antipsychotic medication, electroconvulsive therapy or any combination of these treatments may be necessary. After the acute phase has subsided, psychopharmacological treatment should be continued to decrease the likelihood of relapse or future recurrence.

Psychotropic medications play a critical role in the treatment of major depression. They work to relieve acute episodes and prevent recurrences. For many, drugs work most effectively in conjunction with psychotherapy. Insight-oriented therapy can help you consider how such contributing factors as early experiences of loss and cumulative negative life circumstances and disappointments have colored your outlook. Cognitive techniques can also provide significant relief insofar as they address the negative and distorted thinking that typically characterizes depression. Interpersonal therapy helps the person address problems in relationships.

A variety of electrical stimulation techniques are available to treat depression. The one that has been in longest use is electroconvulsive therapy (ECT or shock treatments.) Although extremely effective for most patients, ECT requires that general anesthesia be administered, and so is usually reserved for emergency situations and in patients who have not responded to medications.

A more recent technique involves using a powerful magnetic field to stimulate deep brain structures. Transcranial magnetic stimulation (TMS) does not require any anesthesia and has now been approved in treatment-resistant depression. Another new technique called vagal nerve stimulation (VNS) uses a pacemaker-like device to deliver short pulses of tiny electrical charges to the brain. The implanted stimulator is connected to the vagus nerve as it travels beneath the neck muscles and sends the electrical pulses up the nerve to its origin deep within the brain.

When to seek treatment
If you are in the throes of depression, you may well believe that you are beyond help. Yet depression can be effectively treated and managed.

If your state of gloom persists for more two weeks, you find that you can't get out of bed, you are increasingly isolated from family and friends and you have lost any sense of enjoyment or interest in your usual activities, call your physician. If you find yourself ruminating about death and the meaningless of life, and you are considering suicide, seek help immediately.

Prognosis
Good. Recent progress in the development of new drugs that have fewer side effects and are effective for more people makes the treatment of depression even more promising. SAD responds well to light therapy.

In some instances, one course of treatment is sufficient to manage or remedy major depressive illness. However, for many others, depression is a recurring condition that requires continued or episodic intervention. Even after a successful round of treatment, it is important that you remain sensitive to stresses that are likely to trigger a depression. If you are able to recognize early signs, you will be able to contact your clinician before you find yourself deep in another depressive episode. Learning to manage depression through therapy, medication and lifestyle will lessen the impact that it has on your life.

Additional information
For additional information about panic disorder, you can contact:

American Psychiatric Association
1000 Wilson Boulevard, Suite 825
Arlington, VA 22209
Phone: (703) 907-7300
www.psych.org

National Institute of Mental Health
NIMH Public Inquiries
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: (301) 443-4513
http://www.nimh.nih.gov/healthinformation/depressionmenu.cfm

Updated: 10/20/2009
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