Getting the Best from your Medicine  




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:

  • Core (key) symptoms:
    • Persistent sadness or low mood. This may be with or without weepiness.
    • Marked loss of interest or pleasure in activities, even for activities that you normally enjoy.
  • Other common symptoms:
    • Disturbed sleep compared with your usual pattern. This may be difficulty in getting off to sleep, or waking early and being unable to get back to sleep. Sometimes it is sleeping too much.
    • Change in appetite. This is often a poor appetite and weight loss. Sometimes the reverse happens with comfort eating and weight gain.
    • Fatigue (tiredness) or loss of energy.
    • Agitation or slowing of movements.
    • Poor concentration or indecisiveness. For example, you may find it difficult to read, work, etc. Even simple tasks can seem difficult.
    • Feelings of worthlessness, or excessive or inappropriate guilt.
    • Recurrent thoughts of death. This is not usually a fear of death, more a preoccupation with death and dying. For some people despairing thoughts such as "life's not worth living" or "I don't care if I don't wake up" are common. Sometimes these thoughts progress into thoughts and even plans for suicide.


    An episode of depression is usually diagnosed if:

    • You have at least five out of the above nine symptoms, with at least one of these a core symptom; and
    • Symptoms cause you distress or impair your normal functioning, such as affecting your work performance; and
    • Symptoms occur most of the time on most days and have lasted at least two weeks; and
    • The symptoms are not due to a medication side-effect, or due to drug or alcohol misuse, or to a physical condition such as an underactive thyroid or pituitary gland

    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:

    • Severe depression - you would normally have most or all of the nine symptoms listed above. Also, symptoms markedly interfere with your normal functioning.
    • Moderate depression - you would normally have more than the five symptoms that are needed to make the diagnosis of depression. Also, symptoms will usually include both core symptoms. Also, the severity of symptoms or impairment of your functioning is between mild and severe.
    • Mild depression - you would normally have five of the symptoms listed above that are required to make the diagnosis of depression. However, you are not likely to have more than five or six of the symptoms. Also, your normal functioning is only mildly impaired.
    • Subthreshold depression - this is where you have less than the five symptoms needed to make a diagnosis of depression. So, it is not classed as depression. But, the symptoms you do have are troublesome and cause distress. If this situation persists for more than two years it is sometimes called dysthymia.




      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.

      • Depression is more common in people who are known to have certain physical conditions.
      • The diagnosis of depression is sometimes confused with some undiagnosed diseases caused by 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:

      • An underactive thyroid gland - can make you feel quite low, weepy, and tired. A blood test can diagnose this.
      • An underactive pituitary gland (hypopituitarism) - the pituitary gland is just under the brain. It makes various hormones which have various actions. Sometimes one hormone can be deficient; sometimes more than one. There are various symptoms that can develop but they can include loss of sex drive, sexual problems, infertility, uncontrollable weight gain and feeling low, depressed and even suicidal. Blood tests can help to diagnose hypopituitarism. There are various causes of hypopituitarism, including head injury.
      • Head injury - even a relatively mild one, even many years ago. For example, studies have shown that rates of suicide (presumably related to depression) are more common than average in people who have previously had a head injury. The reason for this is not fully understood. However, one factor that may be significant in some cases is that a head injury may result in hypopituitarism, as discussed above.
      • Polymyalgia rheumatica - this condition mainly affects older people. Typical symptoms include stiffness, pain, aching, feeling depressed and tenderness of the large muscles around the shoulders and upper arms. Feeling depressed can be the first main symptom before the other symptoms predominate.
      • Early dementia - is sometimes confused with depression.
      • Certain drugs, both prescribed and illicit (street) drugs - can cause side-effects which may mimic depression.




        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

        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:

        • Cognitive behavioural therapy (CBT). Briefly, cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as depression. The therapist helps you to understand your thought patterns. In particular, to identify any harmful or unhelpful ideas or thoughts which you have that can make you depressed. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Behavioural therapy aims to change any behaviours which are harmful or not helpful. CBT is a combination of cognitive therapy and behavioural therapy. In short, CBT helps people to achieve changes in the way that they think, feel and behave.


          • Interpersonal therapy (IPT). This is sometimes offered instead of CBT. IPT is based on the idea that your personal relationships may play a large role in affecting your mood and mental state. The therapist helps you to change your thinking and behaviour and improve your interaction with others. For example, IPT may focus on issues such as bereavement or disputes with others that may be contributing to the depression.


            Other types of therapy sometimes used, depending on circumstances, include:

            • Behavioural activation. The basis of this therapy is that behaviours such as inactivity and ruminating on certain thoughts can be key factors in maintaining depression. The therapist aims to help you to combat these unhelpful behaviours.


            • Couple therapy. This may be an option for people who have a regular partner and where the relationship contributes to the depression. Or, where involving the partner is considered to be of potential useful benefit.


              Other treatments

              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 medicines

              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:

              • With mild depression that persists after other treatments have not helped.
              • Whose depression is associated with a physical illness.
              • Who have had an episode of moderate or severe depression in the past.



                Second-line treatment

                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:

                • It is not clear how well it works. Although some studies suggest that it may help depression, other studies have failed to confirm this.
                • Side-effects sometimes occur. (Some people think that because St John's wort is 'natural' then it is totally safe. This is not true. It contains many chemicals which sometimes cause problems.)
                • It may react with other medicines that you may take. Sometimes the reactions can cause serious problems. For example, you should not take St John's wort if you are taking warfarin, ciclosporin, oral contraceptives, anticonvulsants, digoxin, theophylline, or certain anti-HIV medicines. Also, you should not take it at the same time as certain other prescribed antidepressants.



                  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:

                  • Eating a Mediterranean diet may help to prevent depression. One theory as to why this may help is that a diet high in olive oil may increase the amount of brain chemical called serotonin. This is similar to the effect of some antidepressants.
                  • Magnetic stimulation therapy. A study (cited below) that looked at magnetic stimulation of the brain showed promise to improve depression symptoms.
                  • Omega-3 supplements. One research study (cited below) has reported that some people with depression (but not people with depression and anxiety) had an improvement in symptoms after taking omega-3 supplements (fish oil supplements).
                  • Ketamine. A small study reported that an injection of ketamine improved symptoms for a few days in some people with otherwise treatment-resistant depression.





                    Some dos and don'ts about depression

                    • Don't bottle things up and 'go it alone'. Try to tell people who are close to you how you feel. It is not weak to cry or admit that you are struggling.
                    • Don't despair - most people with depression recover. It is important to remember this.
                    • Do try to distract yourself by doing other things. Try doing things that do not need much concentration but can be distracting, such as watching TV. Radio or TV is useful late at night if sleeping is a problem.
                    • Do eat regularly, even if you do not feel like eating. Try to eat a healthy diet.
                    • Don't drink too much alcohol. Drinking alcohol is tempting to some people with depression as the immediate effect may seem to relieve the symptoms. However, drinking heavily is likely to make your situation worse in the long run. Also, it is very difficult either to assess or to treat depression if you are drinking a lot of alcohol.
                    • Don't make any major decisions whilst you are depressed. It may be tempting to give up a job, or move away, to solve the problem. If at all possible you should delay any major decisions about relationships, jobs, or money until you are well again.
                    • Do tell your doctor if you feel that you are getting worse, particularly if suicidal thoughts are troubling you.
                    • Sometimes a spell off work is needed. However, too long off work might not be so good, as dwelling on problems and brooding at home may make things worse. Getting back into the hurly-burly of normal life may help the healing process when things are improving. Each person is different, and the ability to work will vary.
                    • Sometimes a specific psychological problem can cause depression, but some people are reluctant to mention it. One example is sexual abuse as a child leading to depression or psychological difficulties as an adult. Tell your doctor if you feel something like this is the root cause of your depression. Counselling may be available for such problems.




                      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:

                      • To take an antidepressant long-term to help prevent depression from recurring.
                      • Mindfulness based cognitive therapy. This may be advised (if available) for people who are currently well but have had three or more episodes of depression. This therapy is a specialist type of talking treatment. There is good evidence that it can help to prevent the recurrence of depression. The therapy is typically done in groups of 8 to 15 people and consists of weekly 2-hour meetings over about 8 weeks. And then four follow-up sessions in the 12 months after the end of treatment.




                        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.

                        • People with anxiety, panic disorder, and personality disorders quite commonly also develop depression. As a rule, depression should be treated first, followed by treatment of the other disorder. In particular, anxiety will often improve following treatment of depression.
                        • Eating disorders such as anorexia and bulimia may accompany depression. In this situation the eating disorder is usually the main target of treatment