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The Invisible Disease: Depression

Introduction

Depression is a serious medical condition. 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. There are three main types of depressive disorders: major depressive disorder, dysthymic disorder, and bipolar disorder (manic-depressive illness).

Symptoms and Types of Depression

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 major depressive disorder is made if a person has 5 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 to 30 but also can appear in children. 1 Episodes typically recur.

Some people have a chronic but less severe form of depression, called dysthymic disorder, which is diagnosed when depressed mood persists for at least 2 years (1 year in children) and is accompanied by at least 2 other symptoms of depression. Many people with dysthymia develop major depressive episodes.

Episodes of depression also occur in people with bipolar disorder. In this disorder, depression alternates with mania, which is characterized by abnormally and persistently elevated mood or irritability and symptoms including overly-inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk taking. Because bipolar disorder requires different treatment than major depressive disorder or dysthymia, obtaining an accurate diagnosis is extremely important.

Facts About Depression

Major depression is the leading cause of disability in the U.S. and worldwide. 2 Depressive disorders affect an estimated 9.5 percent of adult Americans ages 18 and over in a given year, 3 or about 18.8 million people in 1998. Nearly twice as many women (12 percent) as men (7 percent) are affected by a depressive disorder each year.

Depression can be devastating to 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. 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 due to feelings of shame and stigma. Too often, untreated or inadequately treated depression is associated with suicide.

Treatments

Antidepressant medications are widely used, effective treatments for depression. Existing antidepressants influence the functioning of certain chemicals in the brain called neurotransmitters. The newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), tend to have fewer side effects than the older drugs, which include tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Although both generations of medications are effective in relieving depression, some people will respond to one type of drug, but not another. Other types of antidepressants are now in development.

Certain types of psychotherapy, specifically cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), have been found helpful for depression. Research indicates that mild to moderate depression often can be treated successfully with either therapy alone; however, severe depression appears more likely to respond to a combination of psychotherapy and medication. 7 More than 80 percent of people with depressive disorders improve when they receive appropriate treatment.

In situations where medication, psychotherapy, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis (e.g., hallucinations, delusional thinking) or suicidality, electroconvulsive therapy (ECT) may be considered. ECT is a highly effective treatment for severe depressive episodes.

The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.

One herbal supplement, hypericum or St. John's wort, has been promoted as having antidepressant properties. Results from the first large-scale, controlled study of St. John's wort for major depression, which was funded in part by NIMH, are expected in 2001. Note: There is evidence that St. John's wort can reduce the effectiveness of certain medications. Use of any herbal or natural supplements should always be discussed with your doctor before they are tried.

Research Findings

Brain imaging research is 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, including studies of twins, indicates that genes play a role in depression. Vulnerability to depression appears to result from the influence of multiple genes acting together with environmental factors.

Other research has shown that stressful life events, particularly in the form of loss such as the death of a close family member, may trigger major depression in susceptible individuals. The hypothalamic-pituitary-adrenal (HPA) axis, the hormonal system that regulates the body's response to stress, is overactive in many people with depression. Research findings suggest that persistent overactivation of this system may lay the groundwork for depression.

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.

New Clinical Trials

NIMH is funding two new, large-scale, multi-site clinical trials on treatments for major depression in adults and adolescents. For more information about these studies'the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project, and the Treatment of Adolescents with Depression Study (TADS)'and others, visit the Clinical Trials page of the NIMH Web site.

For More Information

National Institute of Mental Health (NIMH)
Office of Communications and Public Liaison
Public Inquiries: (301) 443-4513
Media Inquiries: (301) 443-4536
E-mail: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov