symptoms, treatments & medical costs
What Is Depression?

Everyone occasionally feels blue or sad. But these feelings are usually short-lived and pass within a couple of days.
When you have depression, it interferes with daily life and causes pain for both you and those who care about you.
Depression is a common but serious illness.

Many people with a depressive illness never seek treatment. But the majority, even those with the most severe
depression, can get better with treatment. Medications, psychotherapies, and other methods can effectively treat
people with depression.

Different forms of depression

There are several forms of depressive disorders.

Major depressive disorder, or major depression, is characterized by a combination of symptoms that interfere with a
person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major depression is disabling and
prevents a person from functioning normally. Some people may experience only a single episode within their lifetime,
but more often a person may have multiple episodes.

Depression is a common but serious illness. Most who experience depression need treatment to get better.

Dysthymic disorder, or dysthymia, is characterized by long-term (2 years or longer) symptoms that may not be severe
enough to disable a person but can prevent normal functioning or feeling well. People with dysthymia may also
experience one or more episodes of major depression during their lifetimes.

Minor depression is characterized by having symptoms for 2 weeks or longer that do not meet full criteria for major
depression. Without treatment, people with minor depression are at high risk for developing major depressive disorder.

Some forms of depression are slightly different, or they may develop under unique circumstances. However, not
everyone agrees on how to characterize and define these forms of depression. They include:

Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as
having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others
cannot hear or see (hallucinations).

Postpartum depression, which is much more serious than the "baby blues" that many women experience after giving
birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It
is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.1

Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when
there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated
with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant
medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.2

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar
disorder is characterized by cycling mood changes—from extreme highs (e.g., mania) to extreme lows (e.g.,
depression). More information about bipolar disorder is available.

What are the signs and symptoms of depression?

People with depressive illnesses do not all experience the same symptoms. The severity, frequency, and duration of
symptoms vary depending on the individual and his or her particular illness.

Signs and symptoms include:

Persistent sad, anxious, or "empty" feelings
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including sex
Fatigue and decreased energy
Difficulty concentrating, remembering details, and making decisions
Insomnia, early-morning wakefulness, or excessive sleeping
Overeating, or appetite loss
Thoughts of suicide, suicide attempts
Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

I started missing days from work, and a friend noticed that something wasn't right. She talked to me about the time she
had been really depressed and had gotten help from her doctor.

What illnesses often co-exist with depression?

Other illnesses may come on before depression, cause it, or be a consequence of it. But depression and other
illnesses interact differently in different people. In any case, co-occurring illnesses need to be diagnosed and treated.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder,
social phobia, and generalized anxiety disorder, often accompany depression.3,4 PTSD can occur after a person
experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military
combat. People experiencing PTSD are especially prone to having co-existing depression.

In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than 40 percent of people
with PTSD also had depression 4 months after the traumatic event.5

Alcohol and other substance abuse or dependence may also co-exist with depression. Research shows that mood
disorders and substance abuse commonly occur together.6

Depression also may occur with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS,
diabetes, and Parkinson's disease. People who have depression along with another medical illness tend to have more
severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and
more medical costs than those who do not have co-existing depression.7 Treating the depression can also help
improve the outcome of treating the co-occurring illness.8

What causes depression?

Most likely, depression is caused by a combination of genetic, biological, environmental, and psychological factors.

Depressive illnesses are disorders of the brain. Longstanding theories about depression suggest that important
neurotransmitters—chemicals that brain cells use to communicate—are out of balance in depression. But it has been
difficult to prove this.

Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who
have depression look different than those of people without depression. The parts of the brain involved in mood,
thinking, sleep, appetite, and behavior appear different. But these images do not reveal why the depression has
occurred. They also cannot be used to diagnose depression.

Some types of depression tend to run in families. However, depression can occur in people without family histories of
depression too.9 Scientists are studying certain genes that may make some people more prone to depression. Some
genetics research indicates that risk for depression results from the influence of several genes acting together with
environmental or other factors.10 In addition, trauma, loss of a loved one, a difficult relationship, or any stressful
situation may trigger a depressive episode. Other depressive episodes may occur with or without an obvious trigger.

Research indicates that depressive illnesses are disorders of the brain.

Personal Story

It was really hard to get out of bed in the morning. I just wanted to hide under the covers and not talk to anyone. I didn't
feel much like eating and I lost a lot of weight.

Nothing seemed fun anymore. I was tired all the time, and I wasn't sleeping well at night. But I knew I had to keep going
because I've got kids and a job. It just felt so impossible, like nothing was going to change or get better.

How do women experience depression?

Depression is more common among women than among men. Biological, life cycle, hormonal, and psychosocial factors
that women experience may be linked to women's higher depression rate. Researchers have shown that hormones
directly affect the brain chemistry that controls emotions and mood. For example, women are especially vulnerable to
developing postpartum depression after giving birth, when hormonal and physical changes and the new responsibility
of caring for a newborn can be overwhelming.

Some women may also have a severe form of premenstrual syndrome (PMS) called premenstrual dysphoric disorder
(PMDD). PMDD is associated with the hormonal changes that typically occur around ovulation and before menstruation

During the transition into menopause, some women experience an increased risk for depression. In addition,
osteoporosis—bone thinning or loss—may be associated with depression.11 Scientists are exploring all of these
potential connections and how the cyclical rise and fall of estrogen and other hormones may affect a woman's brain

Finally, many women face the additional stresses of work and home responsibilities, caring for children and aging
parents, abuse, poverty, and relationship strains. It is still unclear, though, why some women faced with enormous
challenges develop depression, while others with similar challenges do not.
How do men experience depression?

Men often experience depression differently than women. While women with depression are more likely to have feelings
of sadness, worthlessness, and excessive guilt, men are more likely to be very tired, irritable, lose interest in once-
pleasurable activities, and have difficulty sleeping.13,14

Men may be more likely than women to turn to alcohol or drugs when they are depressed. They also may become
frustrated, discouraged, irritable, angry, and sometimes abusive. Some men throw themselves into their work to avoid
talking about their depression with family or friends, or behave recklessly. And although more women attempt suicide,
many more men die by suicide in the United States.15
How do older adults experience depression?

Depression is not a normal part of aging. Studies show that most seniors feel satisfied with their lives, despite having
more illnesses or physical problems. However, when older adults do have depression, it may be overlooked because
seniors may show different, less obvious symptoms. They may be less likely to experience or admit to feelings of
sadness or grief.16

Sometimes it can be difficult to distinguish grief from major depression. Grief after loss of a loved one is a normal
reaction to the loss and generally does not require professional mental health treatment. However, grief that is
complicated and lasts for a very long time following a loss may require treatment. Researchers continue to study the
relationship between complicated grief and major depression.17

Older adults also may have more medical conditions such as heart disease, stroke, or cancer, which may cause
depressive symptoms. Or they may be taking medications with side effects that contribute to depression. Some older
adults may experience what doctors call vascular depression, also called arteriosclerotic depression or subcortical
ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time,
becoming constricted. Such hardening of vessels prevents normal blood flow to the body's organs, including the brain.
Those with vascular depression may have, or be at risk for, co-existing heart disease or stroke.18

Although many people assume that the highest rates of suicide are among young people, older white males age 85 and
older actually have the highest suicide rate in the United States. Many have a depressive illness that their doctors are
not aware of, even though many of these suicide victims visit their doctors within 1 month of their deaths.19

Most older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a
combination of both.20 Research has shown that medication alone and combination treatment are both effective in
reducing depression in older adults.21 Psychotherapy alone also can be effective in helping older adults stay free of
depression, especially among those with minor depression. Psychotherapy is particularly useful for those who are
unable or unwilling to take antidepressant medication.22,23
How do children and teens experience depression?

Children who develop depression often continue to have episodes as they enter adulthood. Children who have
depression also are more likely to have other more severe illnesses in adulthood.24

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die.
Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these
signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be
difficult to accurately diagnose a young person with depression.

Before puberty, boys and girls are equally likely to develop depression. By age 15, however, girls are twice as likely as
boys to have had a major depressive episode.25

Depression during the teen years comes at a time of great personal change—when boys and girls are forming an
identity apart from their parents, grappling with gender issues and emerging sexuality, and making independent
decisions for the first time in their lives. Depression in adolescence frequently co-occurs with other disorders such as
anxiety, eating disorders, or substance abuse. It can also lead to increased risk for suicide.24,26

An NIMH-funded clinical trial of 439 adolescents with major depression found that a combination of medication and
psychotherapy was the most effective treatment option.27 Other NIMH-funded researchers are developing and testing
ways to prevent suicide in children and adolescents.

Childhood depression often persists, recurs, and continues into adulthood, especially if left untreated.

How is depression diagnosed and treated?

Depression, even the most severe cases, can be effectively treated. The earlier that treatment can begin, the more
effective it is.

The first step to getting appropriate treatment is to visit a doctor or mental health specialist. Certain medications, and
some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor
can rule out these possibilities by doing a physical exam, interview, and lab tests. If the doctor can find no medical
condition that may be causing the depression, the next step is a psychological evaluation.

The doctor may refer you to a mental health professional, who should discuss with you any family history of depression
or other mental disorder, and get a complete history of your symptoms. You should discuss when your symptoms
started, how long they have lasted, how severe they are, and whether they have occurred before and if so, how they
were treated. The mental health professional may also ask if you are using alcohol or drugs, and if you are thinking
about death or suicide.

Once diagnosed, a person with depression can be treated in several ways. The most common treatments are
medication and psychotherapy.

I called my doctor and talked about how I was feeling. She had me come in for a checkup and gave me the name of a
specialist, who is an expert in treating depression.


Antidepressants primarily work on brain chemicals called neurotransmitters, especially serotonin and norepinephrine.
Other antidepressants work on the neurotransmitter dopamine. Scientists have found that these particular chemicals
are involved in regulating mood, but they are unsure of the exact ways that they work. The latest information on
medications for treating depression is available on the U.S. Food and Drug Administration (FDA) website.

Popular newer antidepressants

Some of the newest and most popular antidepressants are called selective serotonin reuptake inhibitors (SSRIs).
Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of
the most commonly prescribed SSRIs for depression. Most are available in generic versions. Serotonin and
norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine

SSRIs and SNRIs tend to have fewer side effects than older antidepressants, but they sometimes produce headaches,
nausea, jitters, or insomnia when people first start to take them. These symptoms tend to fade with time. Some people
also experience sexual problems with SSRIs or SNRIs, which may be helped by adjusting the dosage or switching to
another medication.

One popular antidepressant that works on dopamine is bupropion (Wellbutrin). Bupropion tends to have similar side
effects as SSRIs and SNRIs, but it is less likely to cause sexual side effects. However, it can increase a person's risk for


Tricyclics are older antidepressants. Tricyclics are powerful, but they are not used as much today because their
potential side effects are more serious. They may affect the heart in people with heart conditions. They sometimes
cause dizziness, especially in older adults. They also may cause drowsiness, dry mouth, and weight gain. These side
effects can usually be corrected by changing the dosage or switching to another medication. However, tricyclics may be
especially dangerous if taken in overdose. Tricyclics include imipramine and nortriptyline.


Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. They can be especially
effective in cases of "atypical" depression, such as when a person experiences increased appetite and the need for
more sleep rather than decreased appetite and sleep. They also may help with anxious feelings or panic and other
specific symptoms.

However, people who take MAOIs must avoid certain foods and beverages (including cheese and red wine) that contain
a substance called tyramine. Certain medications, including some types of birth control pills, prescription pain relievers,
cold and allergy medications, and herbal supplements, also should be avoided while taking an MAOI. These
substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI
skin patch may help reduce these risks. If you are taking an MAOI, your doctor should give you a complete list of foods,
medicines, and substances to avoid.

MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause
confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm,
and other potentially life-threatening conditions. MAOIs should not be taken with SSRIs.
How should I take medication?

All antidepressants must be taken for at least 4 to 6 weeks before they have a full effect. You should continue to take
the medication, even if you are feeling better, to prevent the depression from returning.

Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to
give the body time to adjust. Although antidepressants are not habit-forming or addictive, suddenly ending an
antidepressant can cause withdrawal symptoms or lead to a relapse of the depression. Some individuals, such as those
with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, you should consider trying another. NIMH-funded research has shown that
people who did not get well after taking a first medication increased their chances of beating the depression after they
switched to a different medication or added another medication to their existing one.28,29

Sometimes stimulants, anti-anxiety medications, or other medications are used together with an antidepressant,
especially if a person has a co-existing illness. However, neither anti-anxiety medications nor stimulants are effective
against depression when taken alone, and both should be taken only under a doctor's close supervision.

Report any unusual side effects to a doctor immediately.

FDA warning on antidepressants

Despite the relative safety and popularity of SSRIs and other antidepressants, studies have suggested that they may
have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug
Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of
antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4 percent of those
taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2 percent of
those receiving placebos.

This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to
alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking
antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to
include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during
the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior,
or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The
warning adds that families and caregivers should also be told of the need for close monitoring and report any changes
to the doctor. The latest information from the FDA can be found on their website.

Children, adolescents, and young adults taking antidepressants should be closely monitored.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of
antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety
disorders.30 The study was funded in part by NIMH.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used "triptan"
medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation,
hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of
the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other

What about St. John's wort?

The extract from the herb St. John's wort (Hypericum perforatum) has been used for centuries in many folk and herbal
remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of
the top-selling botanical products.

In an 8-week trial involving 340 patients diagnosed with major depression, St. John's wort was compared to a common
SSRI and a placebo (sugar pill). The trial found that St. John's wort was no more effective than the placebo in treating
major depression.31 However, use of St. John's wort for minor or moderate depression may be more effective. Its use in
the treatment of depression remains under study.

St. John's wort can interact with other medications, including those used to control HIV infection. In 2000, the FDA
issued a Public Health Advisory letter stating that the herb may interfere with certain medications used to treat heart
disease, depression, seizures, certain cancers, and those used to prevent organ transplant rejection. The herb also
may interfere with the effectiveness of oral contraceptives. Consult with your doctor before taking any herbal


Several types of psychotherapy—or "talk therapy"—can help people with depression.

Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—are effective
in treating depression. CBT helps people with depression restructure negative thought patterns. Doing so helps people
interpret their environment and interactions with others in a positive and realistic way. It may also help you recognize
things that may be contributing to the depression and help you change behaviors that may be making the depression
worse. IPT helps people understand and work through troubled relationships that may cause their depression or make
it worse.

For mild to moderate depression, psychotherapy may be the best option. However, for severe depression or for certain
people, psychotherapy may not be enough. For teens, a combination of medication and psychotherapy may be the
most effective approach to treating major depression and reducing the chances of it coming back.27 Another study
looking at depression treatment among older adults found that people who responded to initial treatment of medication
and IPT were less likely to have recurring depression if they continued their combination treatment for at least 2 years.

Now I'm seeing the specialist on a regular basis for "talk therapy," which helps me learn ways to deal with this illness in
my everyday life, and I'm taking medicine for depression.

Electroconvulsive therapy and other brain stimulation therapies

For cases in which medication and/or psychotherapy does not help relieve a person's treatment-resistant depression,
electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation.
But in recent years, it has greatly improved and can provide relief for people with severe depression who have not
been able to feel better with other treatments.

Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. He or she sleeps through the
treatment and does not consciously feel the electrical impulses. Within 1 hour after the treatment session, which takes
only a few minutes, the patient is awake and alert.

A person typically will undergo ECT several times a week, and often will need to take an antidepressant or other
medication along with the ECT treatments. Although some people will need only a few courses of ECT, others may
need maintenance ECT—usually once a week at first, then gradually decreasing to monthly treatments. Ongoing NIMH-
supported ECT research is aimed at developing personalized maintenance ECT schedules.

ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually these side effects are
short-term, but sometimes they can linger. Newer methods of administering the treatment have reduced the memory
loss and other cognitive difficulties associated with ECT. Research has found that after 1 year of ECT treatments, most
patients showed no adverse cognitive effects.32

Nevertheless, patients always provide informed consent before receiving ECT, ensuring that they understand the
potential benefits and risks of the treatment.

Other more recently introduced types of brain stimulation therapies used to treat severe depression include vagus
nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS). These methods are not yet commonly
used, but research has suggested that they show promise.

The article above is modified from
National Institute of Mental Health, NIH. August 2013