Depression is common. Symptoms can affect day-to-day life and can become very distressing. Treatments include psychological (talking) treatments and antidepressant medicines. Treatment takes time to work but has a good chance of success. Some people have recurring episodes of depression and require long-term treatment to keep symptoms away.
What is depression?
The word depressed is a common everyday word. People might say "I'm depressed" when in fact they mean "I'm fed up because I've had a row, or failed an exam, or lost my job", etc. These ups and downs of life are common and normal. Most people recover quite quickly. With true depression, you have a low mood and other symptoms each day for at least two weeks. Symptoms can also become severe enough to interfere with normal day-to-day activities.
Who gets depression?
About 2 in 3 adults have depression at some time in their life. Sometimes it is mild or lasts just a few weeks. However, an episode of depression serious enough to require treatment occurs in about 1 in 4 women and 1 in 10 men at some point in their lives. Some people have two or more episodes of depression at various times in their life.
What are the symptoms of depression?
Many people know when they are depressed. However, some people do not realise when they are depressed. They may know that they are not right and are not functioning well, but don't know why. Some people think that they have a physical illness - for example, if they lose weight.
There is a set of symptoms that are associated with depression and help to clarify the diagnosis. These are:
An episode of depression is usually diagnosed if:
Many people with depression say that their symptoms are often worse first thing each day. Also, with depression, it is common to develop physical symptoms such as headaches, palpitations, chest pains, and general aches. Some people consult a doctor at first because they have a physical symptom such as chest pains. They are concerned that they may have a physical problem such as a heart condition when it is actually due to depression. Depression is in fact quite a common cause of physical symptoms. But, the converse is also true. That is, people with serious physical conditions are more likely than average to develop depression.
Some people with severe depression also develop delusions and/or hallucinations. These are called psychotic symptoms. A delusion is a false belief that a person has, and most people from the same culture would agree that it is wrong. For example, a belief that people are plotting to kill you or that there is a conspiracy about you. Hallucination means hearing, seeing, feeling, smelling, or tasting something that is not real.
Severity of depression
The severity of depression can vary from person to person. Severity is generally divided as follows:
What causes depression?
The exact cause is not known. Anyone can develop depression. Some people are more prone to it, and it can develop for no apparent reason. You may have no particular problem or worry, but symptoms can develop quite suddenly. So, there may be some genetic factor involved that makes some people more prone to depression than others.
An episode of depression may also be triggered by a life event such as a relationship problem, bereavement, redundancy, illness, etc. In many people it is a mixture of the two. For example, the combination of a mild low mood with some life problem, such as work stress, may lead to a spiral down into depression.
Women tend to develop depression more often than men. Particularly common times for women to become depressed are after childbirth (postnatal depression) and the menopause.
Depression and physical conditions
Although the cause of depression is not clear, there are some useful things to remember about depression in relation to physical conditions.
Known physical conditions
Depression is more common than average in people coping with serious or severe physical diseases. Although the treatment of the physical disease may take priority, the treatment of depression is also useful to improve overall wellbeing.
Undiagnosed physical conditions
Various physical conditions may at first seem to mimic depression. Doctors aim to be on the lookout for these diseases and may order tests to rule them out if one is suspected. Perhaps the most common examples are:
Some myths and other points about depression
Depression is common, but many people don't admit to it. Some people feel there is a stigma attached, or that people will think they are weak. Great leaders such as Winston Churchill have suffered depression. Depression is one of the most common illnesses that GPs deal with. People with depression may be told by others to "pull their socks up" or "snap out of it". The truth is, they cannot, and such comments by others are very unhelpful.
Understanding that your symptoms are due to depression, and that it is common, may help you to accept that you are ill and need help. Some people ask "Am I going mad?". It may be a relief to know that you are not going mad, and that the symptoms you have are common and have been shared by many other people.
You may 'bottle up' your symptoms from friends and relatives. However, if you are open about your feelings with close family and friends, it may help them to understand and help.
What are the treatment options for depression?
In general, treatments are divided into those used for mild depression and those used for moderate and severe depression.
What if I don't have any treatment?
Most people with depression will get better without treatment. However, this may take several months or even longer. (The average length of an episode of depression is 6-8 months.) Meanwhile, living with depression can be difficult and distressing (and also for your family and friends). Relationships, employment, etc, may be seriously affected. There is also a danger that some people turn to alcohol or illegal drugs. Some people think of suicide. Therefore, many people with depression opt for treatment.
Treatment options for moderate or severe depression
Antidepressant medicines are commonly used to treat moderate or severe depression. A medicine cannot alter your circumstances. However, symptoms such as low mood, poor sleep, poor concentration, etc, are often eased with an antidepressant. This may then allow you to function more normally, and increase your ability to deal with any problems or difficult circumstances.
An antidepressant does not usually work straight away. It can take 2-4 weeks before the effect builds up fully. A common problem is that some people stop the medicine after a week or so as they feel it is not helping. You need to give it time. Also, if it is helping, follow the course that a doctor recommends. A normal course of an antidepressant lasts for at least six months after symptoms have eased. Some people stop their medication too early and the depression may then quickly return.
There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. (The leaflet that comes in the medicine packet provides a full list of possible side-effects.) If the first one that you try does not suit, then another may be found that will suit. So, tell your doctor if you have any problems with an antidepressant. Antidepressants are not tranquillisers and are not thought to be addictive.
People with moderate or severe depression have a good chance of improving within a few weeks of starting an antidepressant. But, they do not work in everybody. However, some antidepressants work better in some people than in others. Therefore, tell your doctor if symptoms do not start to improve after about 3-4 weeks of taking an antidepressant. In this situation it is common to advise either an increase in dose (if the maximum dose is not yet reached) or a switch to another type of antidepressant.
At the end of a course of treatment it is usual to reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if an antidepressant is stopped abruptly.
Psychological (talking) treatments
Various psychological treatments have been shown in research trials to be good treatments for depression. These are briefly listed below. In general, a combination of an antidepressant plus a psychological treatment is better than either treatment alone. Therefore, if available, you should consider having both treatments. However, there may be a shortage in some areas of trained therapists who can perform psychological treatments. Typically, most psychological treatments for depression last in the range of 12-20 weekly sessions of 1-2 hours per session.
Those most commonly used for moderate or severe depression are:
Other types of therapy sometimes used, depending on circumstances, include:
Electroconvulsive therapy (ECT) may be advised as a last resort if you have severe depression which has not improved with other treatments.
What about exercise?
It is difficult to give firm advice about exercise as a treatment. Some people claim that regular exercise helps to lift their mood and help to combat depression. But, there is conflicting evidence about this from research trials. The national guideline published in 2009 by NICE advises regular exercise as a possible treatment. A large review published in 2012 supports this advice concluding that exercise, on average, seems to improve depressive symptoms. In contrast, a large research trial published in 2012 found that the addition of an exercise programme to the usual care for depression did not improve the outcome of depression or reduce the use of antidepressants compared with usual care alone.
But also bear in mind that regular exercise is generally a good thing to do anyway.
Treatment options for mild depression
The following are the commonly used treatment options for people with mild depression. Also, for people with subthreshold depression that has lasted a long time and not shown signs of improving. Some people prefer one type of treatment to another. So, personal preference for the type of treatment used should be taken into account when discussing the best treatment for yourself with your doctor.
A guided self-help programme
There are various pamphlets, books, and audio tapes which can help you to understand and combat depression. The best are based on the principles of CBT, as described earlier. Ideally, a guided self-help programme is best. That is, a programme where the materials are provided by a trained practitioner such as a doctor, and where a practitioner monitors your progress. A self-help programme takes some motivation and effort to work through - a bit like doing homework. A typical guided self-help programme consists of 6-8 sessions (face-to-face and via telephone) over 9-12 weeks.
Computer-based cognitive behavioural therapy
Computer- and internet-based self-help CBT programmes are recent innovations. They are supported by a trained practitioner who monitors progress. A programme typically takes place over 9-12 weeks, and you are given tasks to try out between sessions.
Group-based cognitive behavioural therapy
This is CBT but in a group setting of 8-10 participants. Typically, it consists of 10-12 weekly meetings.
Group-based peer support
This is an option for people with depression who also have an ongoing (chronic) physical problem. This allows sharing of experiences and feelings with a group of people who understand the difficulties and issues facing group members. Typically, it consists of one session per week over 8-12 weeks. Ideally, it should be supported by a facilitator who has knowledge of the physical health problem, and who reviews progress with people taking part in the group.
Antidepressant medication is not usually recommended for the initial treatment of mild depression. However, an antidepressant may be advised for mild depression in certain circumstances. For example, in people:
For mild depression, the above treatments often work well and symptoms improve. However, if symptoms do not improve much with the above treatments, then it is usual to move on to the treatments usually advised for moderate or severe depression, as discussed earlier. That is, an antidepressant and a more intensive psychological treatment such as individual one-to-one CBT.
What about St John's wort (hypericum)?
This is not advised. St John's wort is a herbal antidepressant that you can buy, without a prescription, from pharmacies. It recently became a popular treatment for depression. However, national guidelines for depression do not advise that you take this because:
Some promising possible new treatments
Some newer treatments have recently had some press coverage. None of those listed below is currently routine treatment for depression. However, further research may clarify how useful they are for depression:
Some dos and don'ts about depression
Will it happen again?
A one-off episode of depression at some stage in life is common. However, some people have two, three, or more episodes of depression. You can have treatment for each episode. But, if you are prone to recurring episodes of depression, options that may be considered by you and your docotr include the following:
Seasonal affective disorder
Some people develop recurrent depression in the winter months only. This is called seasonal affective disorder (SAD). For people in the UK with SAD, symptoms of depression usually develop each year sometime between September and November, and continue until March or April. You, and your doctor, may not realise for several years that you have SAD. This is because recurring depression is quite common. You may have been treated for depression several times over the years before it is realised that you have the seasonal pattern of SAD. Treatment of SAD is similar to other types of depression. However, light therapy is also effective.
Other mental health problems
Depression sometimes occurs at the same time as other mental health problems.