Understanding Depression

 | April 1, 2008

Understanding Depression

While sadness touches all of our lives at different times, the illness of depression can have enormous depth and staying power. Even the ancient Greeks noted how disabling it could be, and that it was more than a passing bout of sadness or dejection, or feeling down in the dumps. If you have ever suffered from depression or been close to someone who has, you know that this illness cannot be lifted at will or wished or joked away. A man in the grip of depression can't solve his problems by showing a little more backbone. Nor can a woman who is depressed simply shake off the blues.

Being depressed has nothing to do with personal weakness. Scientists' developing knowledge of brain chemistry and findings from brain imaging studies reveal that changes in nerve pathways and brain chemicals called neurotransmitters can affect your moods and thoughts. These neurological changes may bubble up as symptoms of depression including derailed sleep, suppressed appetite, agitation, exhaustion, or apathy. In addition, genetic studies show that although no single gene prompts depression, a combination of genetic variations may heighten vulnerability to this disease.

Nerve pathways, chemistry, and genetics aren't the whole story, though. Depression could be described as a lake fed by many streams. Its tributaries include traumatic or stressful life events, such as the death of a loved one, and psychological traits, such as a pessimistic outlook or a tendency toward isolation. An episode of depression may result from one particularly powerful experience or from a confluence of several factors. According to the National Institute of Mental Health, during a given year approximately 1 in 10 adults will suffer from some form of depression. Each episode usually affects a chain of people. It can fray bonds between you and your family and friends by spoiling intimacy, sapping emotional resources, and stealing the joy of shared pleasures.

Thankfully, years of research and breakthroughs have made this serious illness easier to treat. Early recognition of the signs of depression is more common than in the past. Newer treatments, such as drugs targeted at specific changes in brain chemistry, can cut short otherwise crippling episodes. A variety of drugs and therapies can also be combined to boost the likelihood of a full remission.

For those beneath its cloud, depression can seem overwhelming. But treatment can let light and hope back into your life.

This report provides information on these and other helpful therapies. Reading it and sharing it with loved ones might help improve your life or the life of someone close to you. And, because depression remains a leading cause of suicide, the information might even be lifesaving.

What is depression?

Just like a rash or heart disease, depression can take many forms. Definitions of depression and the therapies designed to ease this disease's grip continue to evolve. These shifts will continue to percolate through the field as more research flows in.

This special report addresses three main categories of depression:

• major depression

• dysthymia (a lasting, low-level depression)

• bipolar disorder, previously called manic-depressive illness.

These terms don't begin to describe the tremendous variation in people's experiences of depression. Still, while the labels sometimes seem overly simple, they do help clinicians and researchers study depression and exchange information about its various forms. The categories have many overlapping characteristics, but each has its own distinguishing features.

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What is major depression?

Major depression may make you feel as though work, school, relationships, and other aspects of your life have been derailed or put on hold indefinitely. You feel constantly sad or burdened, or you lose interest in all activities, even those you previously enjoyed. This holds true nearly all day, on most days, and lasts at least two weeks. During this time, you also experience at least four of the following signs of depression:

• a change in appetite that sometimes leads to weight loss or gain

• insomnia or (less often) oversleeping

• a slowdown in talking and performing tasks or, conversely, restlessness and an inability to sit still

• loss of energy or feeling tired much of the time

• problems concentrating or making decisions

• feelings of worthlessness or excessive, inappropriate guilt

• thoughts of death or suicide, or suicide plans or attempts.

Other signs can include a loss of sexual desire, pessimistic or hopeless feelings, and physical symptoms such as headaches, unexplained aches and pains, or digestive problems. Depression and anxiety often occur simultaneously, so you may also feel worried or distressed more often than you used to.

Although these symptoms are hallmarks of depression, if you talk to any two depressed people about their experiences, you might well think they were describing entirely different illnesses. For example, one might not be able to summon the energy to leave the house, while the other might feel agitated and restless. One might feel deeply sad and break into tears easily. The other might snap irritably at the least provocation. One might pick at food, while the other might munch constantly. On a subtler level, two people might both report feeling sad, but the quality of their moods could differ substantially in depth and darkness. Also, symptoms may gather over a period of days, weeks, or months.

Despite such wide variations, depression does have certain common patterns. For example, women are almost twice as likely as men to suffer from depression. And while major depression may start at any time in life, the initial episode occurs, on average, during the mid-20s.

Depression or hopelessness may feel so paralyzing that you find it hard to seek help. Even worse, you may believe that treatment could never overcome the juggernaut bearing down.

Yet nothing could be further from the truth. The vast majority of people who receive proper treatment rebound emotionally within two to six weeks and then take pleasure in life once again. When major depression goes untreated, though, suffering can last for months.

Furthermore, episodes of depression frequently recur. About half of those who sink into an episode of major depression will have at least one more episode later in life. Some researchers think that diagnosing depression early and treating it successfully can help forestall such recurrences. They suspect that the more episodes of depression you've had, the more likely you are to have future episodes, because depression may cause enduring changes in brain circuits and chemicals that affect mood (see "The problem of recurrence"). In addition, people who suffer from recurrent major depression have a higher risk of developing bipolar disorder than people who experience a single episode.

Mild, moderate, or severe depression? Experts judge the severity of depression by assessing the number of symptoms and the degree to which they impair your life. Mild: You have some symptoms and find it takes more effort than usual to accomplish what you need to do. Moderate: You have many symptoms and find they often keep you from accomplishing what you need to do. Severe: You have nearly all the symptoms and find they almost always keep you from accomplishing daily tasks.

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What is dysthymia?

Mental health professionals use the term dysthymia (dis-THIGH-me-ah) to refer to a low-level drone of depression that lasts for at least two years in adults or one year in children and teens. While not as crippling as major depression, its persistent hold can keep you from feeling good and can intrude upon your work, school, and social life. If you were to equate depression with the color black, dysthymia might be likened to a dim gray. Unlike major depression, in which relatively short episodes may be separated by considerable spans of time, dysthymia lasts for an average of at least five years.

If you suffer from dysthymia, more often than not you feel depressed during most of the day. You may carry out daily responsibilities, but much of the zest is gone from your life. Your depressed mood doesn't lift for more than two months at a time, and you also have at least two of the following symptoms:

• overeating or loss of appetite

• insomnia or sleeping too much

• tiredness or lack of energy

• low self-esteem

• trouble concentrating or making decisions

• hopelessness.

Sometimes an episode of major depression occurs on top of dysthymia; this is known as double depression.

Dysthymia often begins in childhood, the teen years, or early adulthood. Being drawn into this low-level depression appears to make major depression more likely. In fact, up to 75% of people who are diagnosed with dysthymia will have an episode of major depression within five years.

It's difficult to escape the grasp of untreated dysthymia. Only about 10% of people spontaneously emerge from it in a given year. Some appear to get beyond it for as long as two months, only to spiral downward again. However, proper treatment eases dysthymia and other depressive disorders in about four out of five people.

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What is bipolar disorder?

Bipolar disorder always includes one or more episodes of mania, characterized by high mood, grandiose thoughts, and erratic behavior. It also often includes episodes of depression. During a typical manic episode, you would feel terrifically elated, expansive, or irritated over the course of a week or longer. You would also experience at least three of the following symptoms:

• grandiose ideas or pumped-up self-esteem

• far less need for sleep than normal

• an urgent desire to talk

• racing thoughts and distractibility

• increased activity that may be directed to accomplishing a goal or expressed as agitation

• a pleasure-seeking urge that might get funneled into sexual sprees, overspending, or a variety of schemes, often with disastrous consequences.

Between episodes, you might feel completely normal for months or even years. Or you might experience faster mood swings (known as rapid cycling). Bipolar disorder actually takes many forms. For example, symptoms of depression and mania may be mixed during cycles. Or you might not have full-blown mania; instead, you could have a milder version known as hypomania.

Is pain a symptom of depression or a cause? Pain is depressing, and depression causes and intensifies pain. People with chronic pain have three times the average risk of developing psychiatric symptoms usually mood or anxiety disorders and depressed patients have three times the average risk of developing chronic pain. When low energy, insomnia, and hopelessness resulting from depression or anxiety perpetuate and aggravate physical pain, it can be impossible to tell which came first or where one leaves off and the other begins. Pain slows recovery from depression, and depression makes pain more difficult to treat. For example, depression may cause patients to drop out of pain rehabilitation programs. So it often makes sense to treat both pain and depression; that way they are more likely to recede together. Brain pathways Normally, the brain diverts signals of physical discomfort so that we can concentrate on the external world. When this shutoff mechanism is impaired, physical sensations like pain are more likely to become the center of attention. Brain pathways that handle pain signals use some of the same chemical messengers (neurotransmitters) that are involved in the regulation of mood. (See "Nerve cell communication" for more information.) When these pathways start to malfunction, pain is intensified, along with sadness, hopelessness, and anxiety. And as chronic pain, like chronic depression, takes root in the nervous system, the problem perpetuates itself. The mysterious disorder known as fibromyalgia may be an example of this kind of biological process linking pain and depression. Its symptoms include widespread muscle pain and tenderness at certain pressure points, with no evidence of tissue damage. Brain scans of people with fibromyalgia show highly active pain centers, and the disorder is more closely associated with depression than most other medical conditions. This leads some experts to speculate that the pain sensitivity and emotional storminess of fibromyalgia result from faulty brain pathways. Treating pain and depression in combination In pain rehabilitation centers, specialists treat both problems together, often with the same techniques, including progressive muscle relaxation, hypnosis, and meditation. Physicians prescribe standard pain medications acetaminophen, aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs), and in severe cases, opiates along with a variety of psychiatric drugs. Almost every drug used in psychiatry can serve as a pain medication (see "Medications used for depression and bipolar disorder"). By relieving anxiety, fatigue, or insomnia, these medications also ease any related pain. In addition, antidepressants sometimes given in low doses may relieve pain in ways unrelated to their antidepressant effects. Exercise and psychotherapy are commonly used at pain centers, too. Physical therapists help patients perform exercises not only to break the vicious cycle of pain and immobility, but also to help relieve depression. Cognitive and behavioral therapies teach pain patients how to avoid fearful anticipation, banish discouraging thoughts, and adjust everyday routines to ward off physical and emotional suffering. Psychotherapy helps demoralized patients and their families tell their stories and describe the experience of pain in its relation to other problems in their lives.

Bipolar disorder usually starts in early adulthood. It's equally common among women and men, although certain variations of it strike one sex more than the other. Hypomania, for example, occurs more often in women. Women are also more likely to experience major depression as their first episode and to have more depressive episodes over all. Men, on the other hand, typically experience manic episodes first and tend to have more of them than depressive cycles.

Bipolar disorder is a recurring illness. Nine out of 10 people who have a single manic episode can expect to have repeat experiences. Suicide rates in people who have bipolar disorder are higher than average. Successful treatment, however, can cut down on the number and intensity of episodes and reduce suicide risk.

What are your symptoms? Identifying your symptoms can be a useful first step toward gaining a deeper understanding of how depression, dysthymia, or bipolar disorder affects you. It may help you open a discussion with a doctor or therapist, too. Be aware, however, that self-tests like this one cannot diagnose depression or any other mental illness. Even if they could, it's easy to dismiss or overlook symptoms in yourself. It may help to have a friend or relative go over this checklist with you. Also, remember that your feelings count far more than the number of check marks you make. If you think you are depressed or if you have other concerns or questions after taking this test, talk with your doctor or therapist. Depression checklist Start by checking off any symptoms of depression that you have had for two weeks or longer, or that you've noticed in the family member or friend you're concerned about. Focus on symptoms that have been present almost every day for most of the day. Then look at the key below. (The exception is the item regarding thoughts of suicide or suicide attempts. A check mark warrants an immediate call to a doctor.) I feel sad or irritable. I have lost interest in activities I used to enjoy. I'm eating much less than I usually do and have lost weight, or I'm eating much more than I usually do and have gained weight. I am sleeping much less or more than I usually do. I have no energy or feel tired much of the time. I feel anxious and can't seem to sit still. I feel guilty or worthless. I have trouble concentrating or find it hard to make decisions. I have recurring thoughts about death or suicide, I have a suicide plan, or I have tried to commit suicide. Manic episode checklist Check off any symptoms you've noticed for a week or longer in yourself or the person you're concerned about. Focus on symptoms that are present almost every day during most of the day. I feel extremely elated, uninhibited, or irritable. I have ideas or plans that will have a big impact on myself or on others. I have a continuous stream of thoughts racing through my brain. I am sleeping far less than I normally do. I am talking far more than I normally do. I feel quite distracted and find it hard to focus. I am energetically pursuing my goals, or I feel agitated and unable to sit still. I am actively pursuing pleasures that may have negative consequences, such as buying whatever I want or entering into sexual liaisons or business schemes. Scoring the test Depression and dysthymia. If you checked a total of five or more statements on the depression checklist, including at least one of the first two statements, you (or your loved one) may be suffering from an episode of major depression. If you checked fewer statements, including at least one of the first two statements, you may be suffering from a milder form of depression or dysthymia. Manic episode. Checking off four statements on the manic episode checklist, including the first statement, suggests possible bipolar disorder. Note that hypomanic symptoms (milder manic symptoms) may last for as little as four days, not a full week or longer.

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What causes depression?

It's often said that depression results from a chemical imbalance, but that figure of speech doesn't capture how complex the disease is. Depression has many causes, including genetic vulnerability and other influences such as life events, illnesses, and medications.

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Genes

Every part of your body, including your brain, is controlled by genes. Genes make proteins that are involved in biological processes. Throughout life, different genes turn on and off, so that in the best case they make the right proteins at the right time. But if the genes get it wrong, they can alter your biology in a way that results in your mood becoming unstable. In a vulnerable person, any stress (a fight with your spouse, a missed deadline at work, or a medical illness, for example) can then push this system off balance.

To be sure, chemicals are involved in this process, but it is not a simple matter of one chemical being too low and another too high. Rather, many chemicals are involved, working both inside and outside nerve cells. There are millions, even billions, of chemical reactions that make up the dynamic system that is responsible for your mood, perceptions, and how you experience life. With this level of complexity, you can see how two people might have similar symptoms of depression, but the problem on the inside, and therefore what treatments will work best, may be entirely different.

The fact that depression and bipolar disorder run in families has long been clear, but experts now have a developing picture of how much of that tendency comes from nature and how much reflects nurture. Studies of twins and adopted children, plus a wealth of research from the Human Genome Project and the Human Genetics Initiative at the National Institute of Mental Health, have begun to answer some important questions.

The clearest genetic link is to bipolar disorder. Most experts believe it affects 1% of the general population, although some preliminary evidence suggests it could be even more common. Half of those with bipolar disorder have a relative with a similar pattern of mood fluctuations. Studies of identical twins, who share a genetic blueprint, show that if one twin has bipolar disorder, the other has a 60%80% chance of developing it, too. These numbers don't apply to fraternal twins who, like other biological siblings, share only about half of their genes. If one fraternal twin has bipolar disorder, the other has a 20% chance of developing it.

The genetic components of other mood disorders are far harder to pin down. A person who has a first-degree relative who suffered major depression has a 1.5%3% higher-than-normal risk of experiencing the condition as well. But researchers have found it quite difficult to sort out the actual influence of genes versus environmental factors.

Thus far, experts say genes alone are not responsible for causing mood disorders. Rather, these illnesses probably result when genes make a person vulnerable; then the illness is triggered by environmental factors like early losses or long-term stress.

Research indicates that a person's genes also affect how well he or she responds to different treatments. Although we do not yet have genetic tests to help us choose the best treatment, such tests may not be too far off (see "On the horizon").

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The brain

Popular lore has it that emotions reside in the heart. Science, though, tracks the seat of your emotions to the brain. While researchers believe that brain chemicals and neural pathways have a major impact on depression, their understanding of the neurological underpinnings of mood is incomplete. The outer edges of the puzzle appear to be in place, but scientists are working to fill huge gaps in knowledge.

Figure 1: Areas of the brain affected by depression Depression affects several areas of the brain that play a role not just in mood, but also in memory and other mental and physical functions. The cerebral cortex coordinates functions like speech, movement, memory, and learning. The thalamus receives and relays sensory information. The hippocampus processes long-term memories, while the amygdala oversees emotionally charged memories.

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Hormones and the HPA axis

Just as neurotransmitters help ferry signals along nerve pathways, other complex chemicals called hormones carry messages to organs or groups of cells throughout the body. These chemicals trigger or regulate certain activities, such as the release of an egg from a woman's ovary and the delicate control of blood sugar levels.

The hypothalamus in your brain, the pituitary gland below your brain, and the adrenal glands atop your kidneys form a trio known as the hypothalamic-pituitary-adrenal (HPA) axis. Together these structures govern a multitude of hormonal activities in the body and may play a role in depression as well.

The hypothalamus secretes corticotropin-releasing hormone (CRH), a hormone vital to rousing your body when a physical or emotional threat looms. This hormone follows a pathway to your pituitary gland, where it stimulates the secretion of adrenocorticotropic hormone (ACTH), which pulses into your bloodstream. When ACTH reaches your adrenal glands, it triggers the release of cortisol. The boost in this hormone prompts a cascade of reactions in your body that can help you respond quickly to a threat.

Stress hormones race through your bloodstream, preparing you to fight or flee. Your heart beats faster up to five times as quickly as normal and your blood pressure rises. Your breath quickens as your body takes in extra oxygen. Sharpened senses, such as sight and hearing, make you more alert. This release of stress hormones is often called the stress response.

Normally, a feedback loop allows the body to turn off these defenses when the threat passes. In some cases, though, the floodgates never close properly, and cortisol levels rise too often or simply stay high. This can contribute to problems such as high blood pressure, immune suppression, asthma, and possibly depression.

Studies have shown that people who are depressed or have dysthymia typically have increased levels of CRH. Antidepressants and electroconvulsive therapy are both known to reduce these high CRH levels (see "Medications used for depression and bipolar disorder" and "Electroconvulsive therapy"). As CRH levels return to normal, depressive symptoms recede.

CRH is also distributed through the cerebral cortex, part of the amygdala, and the brainstem. When you face severe stress, this hormone is thought to play a major role in coordinating your hormonal defenses, thoughts and behaviors, emotional reactions, and involuntary responses. The neural pathways that carry the effects of CRH beyond the HPA axis reach other regions of the brain as well, and they link with neurons that release serotonin and norepinephrine. Disturbances in hormonal systems, therefore, may well affect neurotransmitters and vice versa. Research suggests that trauma during childhood can negatively affect the functioning of CRH and the HPA axis throughout life.

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Early losses, life events, and temperament

Physical factors such as genes, hormones, and brain function aren't the only contributors to depression; life events also play a role. Profound early losses, such as the death of a parent or the withdrawal of a loved one's affection, may resonate throughout life, eventually expressing themselves as depression. When an individual is unaware of the wellspring of his or her illness, he or she can't easily move past the depression. Moreover, unless the person gains a conscious understanding of the source of the condition, later losses or disappointments may trigger its return.

The British psychiatrist John Bowlby focused on early losses in a number of landmark studies of monkeys. When he separated young monkeys from their mothers, the monkeys passed through predictable stages of a separation response. Their furious outbursts trailed off into despair, followed by apathetic detachment. Inwardly, the levels of their stress hormones rose. Later investigators extended this research. One study found that the stress response specifically the CRH system and HPA axis got stuck in overdrive in adult rodents that had been separated from their mothers too early in life. This held true whether or not the rats were purposely put under stress. Some research suggests that having an overactive HPA axis may lay the groundwork for depression (see "Hormones and the HPA axis").

Interestingly, antidepressants and electroconvulsive therapy relieve the symptoms of animals distressed by such separations.

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Medical problems and mood changes

Certain medical problems are linked to lasting, significant mood disturbances either the sadness or loss of pleasure typical of depression or the elation or hyperirritability seen in mania. In fact, medical illnesses or medications may be at the root of up to 10%15% of all depressions.

Among the best-known culprits are two thyroid hormone imbalances. An excess of thyroid hormone (hyperthyroidism) can trigger manic symptoms. Hyperthyroidism occurs in about two and a half million Americans. Hypothyroidism, a condition in which your body produces too little thyroid hormone, often leads to exhaustion and depression. This imbalance affects more than nine million Americans.

Heart disease has also been linked to depression, with up to half of heart attack survivors reporting feeling blue and many having significant depression. Depression can spell trouble for heart patients: It's been linked with slower recovery, future cardiovascular trouble, and a higher risk of dying within about six months. Although doctors have hesitated to give heart patients older depression medications called tricyclic antidepressants (TCAs) because of their impact on heart rhythms, newer drugs such as selective serotonin reuptake inhibitors (SSRIs) seem safe for people with heart conditions.

The following medical conditions have also been associated with mood disorders:

• degenerative neurological conditions, such as multiple sclerosis, Parkinson's disease, Alzheimer's disease, and Huntington's disease

• stroke

• ₁₂ some nutritional deficiencies, such as a lack of vitamin B

• other endocrine disorders, such as problems with the parathyroid or adrenal glands that cause them to produce too little or too much of particular hormones

• certain immune system diseases, such as lupus

• some viruses and other infections, such as mononucleosis, hepatitis, and HIV

• cancer

• erectile dysfunction in men.

When considering the connection between health problems and depression, an important question to address is which came first, the medical condition or the mood changes. There is no doubt that the stress of having certain illnesses can trigger depression. In other cases, depression precedes the medical illness and may even contribute to it. To find out whether the mood changes occurred on their own or as a result of the medical illness, a doctor carefully considers a person's medical history and the results of a physical exam.

If depression or mania springs from an underlying medical problem, the mood changes should disappear after the medical condition is treated. If you have hypothyroidism, for example, lethargy and depression often lift once treatment regulates the level of thyroid hormone in your blood. In many cases, however, the depression is an independent problem, which means that in order to be successful, treatment must address depression directly.

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Suicide: Recognizing the risk

Most people who commit suicide are depressed, but what triggers this irrevocable step varies from person to person. Suicide may stem from intense feelings of anger, despair, hopelessness, or panic. Sometimes it's carried out under the sway of a highly distorted or psychotic idea. If you think you might harm yourself, seek help. If you believe a friend or loved one might become self-destructive, urge him or her to do the same.

A number of factors can put someone at a higher risk for suicide in the short term, including:

• an episode of depression, psychosis, or anxiety

• a significant loss, such as the death of a spouse or the loss of a job

• loss of social support, for example, because of a move or when a close friend relocates

• a personal crisis or life stress, especially one that increases a sense of isolation or leads to a loss of self-esteem, such as a separation or divorce

• an illness or taking medication that triggers a change in mood.

None of these circumstances necessarily leads to suicide. In fact, most people in these circumstances do not commit suicide, and there is no way to predict who will. But any blow that upsets a person's life can set a vulnerable individual on a self-destructive course. Treatment can help you or someone you care about change that course.

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Other grounds for concern

Mental health experts also observe that many cases of suicide involve some of the following factors. Although these circumstances can't reveal states of mind or predict actions, they should be taken seriously. Family members and health care professionals may be able to reduce the chances of suicide by watching for these factors and taking action if they notice them.

Family history. People who have a biological relative with a history of suicide or suicide attempts have a risk of suicide that is much higher than average. For example, the child of a person who attempts suicide has six times the average risk of committing suicide. And 13% of people with an identical twin who commits suicide take their own lives, compared with less than 1% among fraternal twins. Some research indicates that this apparent inherited vulnerability may be the product of common genes that alter brain function in a way that predisposes a person toward rage and impulsive behavior. However, the gene studies are preliminary, and brain function also varies with a person's circumstances.

Access to handguns. In the United States, although not in other countries, most suicides are by gunshot. The suicide rate is among the highest in those states where gun ownership is highest (Nevada and Montana) and among the lowest in those states with the fewest gun owners (New York and New Jersey). The American Academy of Pediatrics has urged parents to keep guns and ammunition out of the house if a child might be depressed or suicidal. The same recommendation holds true for adults.

Substance abuse. The combination of depression and alcohol or drug use can be deadly because these substances can erase inhibitions and anxiety that might help keep suicide at bay. Or, as the more pleasing effects of such self-medication wear off, hopelessness may return or intensify.

Previous attempts. When someone has survived one or more attempted suicides, friends and relatives may take further attempts less, rather than more, seriously. But people with a history of a suicide attempt are about 40 times more likely to commit suicide than those who haven't attempted it before.

Setting affairs in order. Individuals who have decided on suicide may sort out their finances, give away mementos, or call or visit loved ones. People who have been agitated or depressed may seem calmer and happier. Rather than being a sign of returning health, this shift may stem from their relief at having made a final decision. Although this phenomenon is usually noted only in hindsight, friends and family members may be in the position to recognize it before a doctor or counselor does.

Suicides in the United States Reliable statistics on suicide aren't easy to compile because reporting is not always candid and records are not always thorough. Family members and others may have many reasons for denying that a death is suicide, and official sources cannot always distinguish suicide from accidents in cases like automobile accidents and drug overdoses. Still, despite these limitations, we know that suicide is an important public health problem. Here is a look at some of the figures that are available: Suicide is the 11th leading cause of death in the United States. In 2005, the number of known suicide deaths in the United States was 32,637. Men account for 80% of suicide victims. Whites are twice as likely to commit suicide as blacks and Hispanics. The risk of suicide rises with age, and older Americans are disproportionately likely to die by suicide. According to the National Institute of Mental Health, individuals ages 65 and older made up 13% of the population, but accounted for 18% of all suicide deaths in 2000. Adolescents constitute a growing percentage of suicides. People ages 1524, who once accounted for 5% of suicides, now account for 13%. Suicide is the third leading cause of death among American adolescents.

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How is depression diagnosed?

Although depression is by no means a silent disease, it is seriously underdiagnosed. Experts estimate that only 34% of people with depression seek help, and only one-third of those who have major depression get the help they need.

When people do reach out for help, doctors typically diagnose depression by asking about feelings and experiences. They may also use screening tools and look for possible medical causes by performing a physical exam and sometimes ordering lab tests.

A physical exam and medical history may offer clues that point to depression caused by medication or an underlying illness. In these cases, blood tests or x-rays may confirm the problem. Often, when people are unable or unwilling to recognize their own depression, their initial complaints are medical. Headaches, stomach problems, sexual difficulties, and lack of energy are among the more common medical complaints.

If your symptoms suggest depression and medical causes seem unlikely, your doctor will be interested in hearing whether you've had any feelings of sadness or hopelessness and whether you've noticed any changes in your appetite, sex drive, or sleep patterns. He or she may also ask these questions:

• Have you or anyone in your family ever suffered from depression or another mental disorder? If so, how was it treated?

• Do you get satisfaction and pleasure from your life?

• Do you ever have thoughts about suicide or have you attempted suicide?

• Do you drink alcohol? If so, how often and how much?

• Do you use any drugs such as marijuana, cocaine, crack, or heroin to get high or relax? If so, which drugs and how often?

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Screening for depression

To help identify depression, doctors may use such screening tools as these:

• Self-report scales, which present you with a checklist of symptoms to fill out. These scales may pick up some symptoms or subtle mood changes that otherwise might not be identified.

• Scales completed by a clinician, which are slightly better at detecting depression than self-reports.

• An interview by a doctor or therapist.

Because you may minimize symptoms or may not even be aware of them, your doctor or therapist may want to speak to someone close to you. Where a child or teen is concerned, the doctor may interview parents and, when possible, teachers or a guidance counselor.

When other tests may be useful There is no lab test to determine whether you have depression. Depression is a clinical diagnosis based upon a set of symptoms. Most doctors do not embark on a battery of lab tests for many reasons. Tests can be costly and may not be covered by insurance. In some cases, results point the doctor in the wrong direction, leading to more tests and unnecessary anxiety. Usually, self-reports of symptoms combined with the clinical skills of a doctor or therapist are enough to begin treatment of depression or bipolar disorder. Sometimes, however, a doctor may suspect that your depression is associated with another health reasons, such as an underactive thyroid gland or early dementia. Your doctor may suggest certain tests to confirm a diagnosis, tease out information, or distinguish depression from other psychological or neurological problems. Your doctor may ask you to take any of the following: Psychological tests, during which you answer questions, respond to pictures, or perform tasks like sorting cards or drawing pictures. These tests can give your doctor a better sense of your coping mechanisms, your temperament, or your ability to organize and plan. Tests that look at the brain, such as an EEG or MRI, which can help identify causes of dementia or some rare causes of depression. Both tests are painless. During an EEG, electrodes taped to your scalp pick up electrical signals. An MRI uses magnets, a radio wave transmitter, and a computer to pick up small changes in energy in hydrogen molecules in your brain and process the data to make a detailed scan of your brain. Tests for biological causes of depression, such as a blood test to check thyroid function.

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Treating depression

If we were all carbon copies of one another, identifying the causes of depression and its proper treatment would be simpler. But unique differences in life experience, temperament, and biology make treatment a complex matter. No single treatment works for everyone. However, research suggests that many people benefit from a combination of medication and therapy (see "Drugs and therapy: A winning combination?").

Often, treatment is divided into three phases. Keep in mind, though, that there are no sharp lines dividing the phases, and very few people take a straight path through them.

• In the acute phase, the aim is to relieve your symptoms. Generally, this occurs within 612 weeks, but it may take longer depending on your response to the first treatments you try.

• In the continuation phase, you work with your doctor to maximize your improvements. Further treatment adjustments, such as modifying dosage of a medication, can help. This period takes another four to five months.

• In the maintenance phase, the aim is to prevent relapse. Ongoing treatment is often necessary, especially if you have already experienced several depressive episodes, have chronic low mood, or have risk factors that make a recurrence more likely.

Who should you see for treatment? On your road to treatment, your primary care doctor may be your first stop. A good primary care doctor can assess your symptoms with an eye to whether you have any underlying medical problems. If your doctor believes that depression is the main problem, he or she may suggest an antidepressant. Sometimes the initial response to the medication is good. If so, you may not need to go further. However, if you don't respond well to the first medication, your doctor may refer you to a mental health professional, such as a psychiatrist, psychologist, social worker, or psychiatric nurse. Most primary care doctors aren't equipped to do a more detailed review of the mood problem or to take treatment further with psychotherapy or different medications. You can also find a mental health professional through a local clinic or hospital or through recommendations from family members or friends. While some insurance plans leave the choice of therapist up to you, others limit you to professionals enrolled in their networks. Therefore, it's worthwhile to check with your insurer before choosing a doctor. Since states have different requirements about who may hang out a shingle as a therapist, inquire about the therapist's training, and opt only for one who has been formally trained and certified (see "Ten questions to ask when choosing a therapist"). Some people like to meet with a few therapists before making the commitment to work with one. Even the most highly recommended person may not be the right match for you. Beginning therapy can be uncomfortable, but if a therapist's demeanor or office set-up puts you off, you needn't waste your time trying to make the situation work.

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What you should know about medications

Often, medications are the first choice in treatment, especially if you're experiencing a severe depression or suicidal urges. Controlled studies have found that about 65%85% of people get some relief from antidepressants, compared with 25%40% of people taking a placebo (a pill with no biologically active ingredient). But the very same drug that works wonders for a friend may fail to ease your symptoms. You may need to try a few different medications to find the one that works best for you with as few side effects as possible. In some cases, a doctor may prescribe a combination of antidepressants or an antidepressant along with a drug to treat anxiety or distorted thinking. A drug combination may be more effective than either drug alone.

Doctors usually first prescribe medications from a class of drugs known as selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). Although the side effects of each drug vary slightly from person to person, you have an equal chance of success on any of these drugs. If you don't have a good response to the first drug you try, you and your doctor may decide to switch to another.

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Medications for depression

More medications are available to treat depression than ever before. Some antidepressant classes have fallen out of favor, while others have risen in popularity. Currently, the most commonly prescribed antidepressants are drugs that have been developed since the mid-1980s. SSRIs lead the list in popularity. Some medications don't fall into one class. They include bupropion (Wellbutrin), mirtazapine (Remeron), venlafaxine (Effexor), and duloxetine (Cymbalta). Two older classes of antidepressants, tricyclic antidepressants (TCAs) and MAOIs, are still very useful some people take them without being bothered by side effects but on average their side effects have made them less appealing as a first-line treatment.

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Medications for bipolar disorder

Lithium is the most widely known medication used to treat bipolar disorder. Lithium helps stabilize moods. Other medications also have this effect for example, some anticonvulsants (which are often used to combat seizures) also have mood-stabilizing properties. These mood stabilizers tend to be mainstays for treating bipolar disorder, but your doctor may recommend other medications as well. Depending on the nature of your illness, you may receive antipsychotic, antidepressant, or anti-anxiety medications.

Keep in mind that you may need to stay on some medication or combination of medications indefinitely to keep your mood stable. The likelihood of having a relapse when you go off medications is great, especially if you've had two or more episodes of mania or depression. Experts now believe that the more episodes of depression or mania you've experienced, the more intense and frequent your subsequent episodes may be. Therefore, for people with bipolar disorder, maintenance therapy is the best strategy.

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Psychotherapy for depression and bipolar disorder

Depression can bring everything in your life work, relationships, school, and even the most minor tasks to a grinding halt, or, at the very least, gum up the works. The aim of psychotherapy is to relieve you of symptoms and to help you manage your problems better and live the healthiest, most satisfying life you can.

Some evidence suggests that by encouraging more constructive ways of thinking and acting, psychotherapy makes future bouts of depression less likely. Three schools of psychotherapy cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy play a primary role in combating depression.

Which type of psychotherapy works best? There's no simple answer. Just as people respond differently to different drugs, you might do better with one type of therapy than with another. Many people find that a blended approach one that draws on elements of different schools of psychotherapy suits them best.

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Electroconvulsive therapy

One Flew Over the Cuckoo's Nest Reality often fails to jibe with movies and books. While psychotherapy and antidepressants have garnered some positive fictional portrayals, electroconvulsive therapy (ECT) typically evokes only frightening pictures. More than 30 years after won its Academy Awards, the images from the film linger in many people's minds. Yet ECT remains one of the most effective treatments for severe depression, with response rates of 80%90% for people with major depression. ECT may also be used to treat mania when a person fails to respond to other treatments.

Despite its effectiveness, doctors usually reserve ECT for situations in which several drugs have failed. That's partly because of its technical complexity, and partly because of its negative image.

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Newer approaches

Two newer treatments are geared toward people who haven't responded well to other, more traditional approaches. While they are somewhat similar to ECT, in that they rely on delivering impulses (electrical or magnetic) to achieve results, neither has the proven track record of ECT.

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Complementary therapies for depression

Depression is one of the top five conditions for which people turn to complementary and alternative therapies, such as herbal treatments, exercise, relaxation or meditation exercises, and acupuncture. Of the complementary approaches that have been tested in scientific trials, some show better results than others.

Many people don't tell their doctors what alternative therapies they're using, but it is important to do so. Sometimes a complementary treatment has a problematic interaction with a medication your doctor is prescribing for you. Also, your doctor may be able to offer advice about that particular alternative therapy.

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Herbs and supplements

It wasn't long ago that no one had heard of St. John's wort, let alone SAMe. But now, many people are trying supplements for their depression. But before you try any treatment, be sure to ask: Does it work, and is it safe?

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Meditation

Meditation is a systematic method of regulating your attention, often through focusing on your breathing, a phrase, or an image. It may include calmly dismissing distracting thoughts and feelings while sitting in a relaxed position with your eyes closed.

Meditation is used to relieve stress and elicit the relaxation response, a state of profound rest and release. Some experts believe that by regularly practicing techniques that evoke the relaxation response, such as meditation, you can help your body erase the cumulative effects of stress, which has been linked to health problems such as high blood pressure, heart disease, a weakened immune system, and asthma. As noted earlier, there appears to be a link between stress and depression (see "Hormones and the HPA axis").

Studies have found that meditation can help prevent relapse in people who have had three or more episodes of depression. For example, in one study, while 78% of depressed people given normal treatment for depression relapsed in the following year, only 36% of those people who got meditation training in addition to regular treatment did. For people with fewer than three episodes of depression, meditation has not been found to be as effective.

There is evidence that meditation has distinct effects on the brain. In one study, researchers measured brain electrical activity before, immediately after, and four months after a two-month course in mindfulness meditation. They found persistent increased activity on the left side of the prefrontal cortex, which is associated with joyful and serene emotions.

Another goal of meditation is to facilitate personal change much the same goal as psychotherapy. Some therapists, particularly those in the cognitive behavioral field, have incorporated meditation techniques into therapy, either as part of the session or as homework for patients to do on their own. If meditation appeals to you, ask your therapist about how best to use it. Going to a class or listening to a meditation tape may be a good first step. In addition, try the meditation exercises listed below.

Meditation exercises Here is a meditation exercise that you can try on your own. Choose a mental device to help you focus. Silently repeat a word, sound, prayer, or phrase (such as "one," "peace," "Om," or "breathing in calm"). You may close your eyes if you like, or focus your gaze on an object. Adopt a passive attitude. Disregard distracting thoughts or concerns about how well you're doing. Any time your attention drifts, simply say, "Oh, well" to yourself and return to silently repeating your focus word or phrase. Now slowly relax your muscles, moving your attention gradually from your face to your feet. Breathe easily and naturally while using your focal device for 10 to 20 minutes. After you finish, sit quietly for a minute or so with your eyes closed. After you open your eyes, wait another minute before standing up. Try to practice this meditation daily for 10 to 20 minutes or longer, preferably at a specific time each day. Have just a minute or two? Try the following quick meditation exercise to help relieve stress. Place your hand just beneath your navel so you can feel the gentle rise and fall of your belly as you breathe. Breathe in. Pause for a count of three. Breathe out. Pause for a count of three. Continue to breathe deeply for one minute, pausing for a count of three after each inhalation and exhalation.

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Overcoming barriers to treatment

In a perfect world, every treatment would be right on the mark, every doctor or therapist would earn his or her patient's confidence, and people would find it easy to follow each bit of helpful advice. Clearly, this isn't the reality. So what are some of the barriers to getting good treatment and sticking with it? And how can you surmount them?

If you're finding it difficult to get past some barrier to treatment, share your concerns with your doctor.

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The health care system

Navigating the health care system isn't always easy. Some health insurance companies confine your choices to a narrow panel of doctors or therapists. Or there may be relatively few mental health professionals in your area. It may also be hard to advocate for yourself, especially when you're depressed. Perhaps a supportive family member can help you deal with your insurance plan or accompany you to an appointment.

Most private insurers, Medicare, and managed-care plans provide some coverage for mental health treatments. However, copayments may be higher than for other types of care. There may also be a limit on how many visits the company will cover. Calling your insurer is the best way to figure out your out-of-pocket cost.

If a psychiatrist or doctor is prescribing your medication and another person is conducting psychotherapy, it may be difficult to coordinate the different aspects of your care. Let both people know that it is important to you that they talk with each other.

It's also important that you do all you can to understand your treatment. Bringing a pad and paper to your appointment and taking notes may help you take in information that is sometimes confusing. For example, studies show that although doctors report telling patients about side effects, many patients don't remember hearing that information. Also, make sure you bring up any important and possibly time-consuming issues at the beginning of your appointment. Appointment time is often limited, so plan to make good use of the time, and make follow-up appointments when necessary.

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Finding the best treatment

Choosing the right treatment is difficult. While research provides guidance, it doesn't always point individuals in a specific direction. Which treatment works best for which person is still an open question. It's common to adjust dosages and switch or add drugs depending on your response and side effects. This can be a frustrating process, but your doctor isn't treating you like a guinea pig rather, it's a normal part of good treatment. Until researchers discover a way to predict an individual's response to treatment, this step-by-step, trial-and-error process is the state of the art. With persistence, you can reach your goal.

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Sticking with treatment

Obviously, no treatment plan has a chance to work if it's not followed. Yet many, if not most, people don't take medicines exactly as prescribed, especially if they must take more than one drug at different times of the day.

An estimated 5% of patients flatly refuse to take antidepressants or mood stabilizers. Side effects make these drugs intolerable for another 10%15% and may encourage countless others to occasionally skip pills, tinker with dosages, or stop taking a drug without their doctors' knowledge. If you're having trouble with your medication, talk to your doctor or therapist. He or she can help you sort out the problem and make adjustments if necessary.

Some people who opt for therapy find that it can be difficult to keep at it. Change isn't easy. Even when you're willing to make life changes, the resulting ripples may affect your friends, coworkers, spouse or partner, and children, some of whom may not be as supportive as you'd like. It sometimes helps to encourage those most important to you to join you in a therapy session or to attend support groups.

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Still a stigma

Finally, there's stigma. Many people still erroneously see symptoms of depression and seeking treatment as a sign of weak character, lack of fortitude, or an inability to pull oneself up by the bootstraps. Because depression can be a source of shame, people with this illness may suffer silently. But by not getting treatment, they remain stuck on a destructive course that leads to more pain, a poorer quality of life, and, at worst, suicide.

This description is stark, but there's hope. Therapy and medications can help tremendously, and given the advances in our understanding of this condition, it seems likely that people with depression will soon have even greater treatment options. Public awareness about depression is growing, partly as a result of national public service campaigns, and perhaps funding for the development of new treatments will follow suit. As more and more people seek treatment, it may also be easier for families and friends of those suffering from depression to be more active in encouraging them to get help.

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Managing side effects

immediately No matter what medications you take, always tell your doctor about uncomfortable or worrisome side effects . You and your doctor can often alleviate side effects with a few simple steps. Here are some suggestions for dealing with common side effects of antidepressants:

Dry mouth. Drink a lot of water, chew sugarless gum, and brush your teeth frequently.

Constipation. Eat whole grains, bran cereal, prunes, and hearty servings of fruits and vegetables. Drink plenty of water.

Trouble urinating. If you have difficulty starting urination, your doctor may be able to adjust your medication to relieve this problem.

Dizziness. Sudden changes in position can lead to a sharp drop in blood pressure that causes dizziness. To counter this effect, rise slowly from a chair or when getting out of bed. Also, drink plenty of fluids.

Daytime drowsiness. This problem usually occurs at the beginning of treatment and may not last long. In some cases, it may help to take medication at bedtime, but ask your doctor about this first. If you feel drowsy, don't drive or use heavy equipment.

Trouble sleeping. Sleep often improves after a few weeks, but sometimes a mild sleep aid or a switch to another medication is necessary.

Nausea. Often, nausea disappears within a few weeks. It may help to take the drug shortly after a substantial meal.

Agitation. You might feel uncomfortably nervous or restless after you start taking a drug. Jittery feelings may pass within a few weeks. But in relatively rare cases, agitation will persist; sometimes it's an early symptom of worsening depression or mania.

Headache. Headaches may come and go. Some persist, but they usually disappear within a few weeks.

Sexual difficulties. Sometimes sexual problems are transient or not related to the drug. Talk with your doctor about sexual problems that don't pass soon. Also, see "Sexuality and SSRIs."

If side effects continue to bother you, your doctor may change your dosage, shift the time of day that you take the medication, or split the dosage into smaller amounts to be taken over the course of the day. Or he or she may recommend combining the drug with another one, switching to a different drug, or replacing drugs with therapy or other forms of treatment.

Call your doctor right away if you feel more depressed instead of less or if you feel worse for any reason.

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The problem of recurrence

When depression isn't treated, there's a high likelihood that it will recur. Roughly half of those who have a single untreated episode of major depression will go on to have another. The second untreated episode boosts the odds of a third. Once that occurs, the chances of having a fourth episode are 90%. Over a lifetime, people with untreated major depression will have an average of five to seven episodes, and episodes often accelerate, becoming more frequent and more severe.

Bipolar disorder, dysthymia, and all other mood disorders are also more likely to persist or recur if they go untreated. As with depression, episodes occur more frequently and become more intense over time. This suggests that it's best to treat major depression, bipolar disorder, and dysthymia as early as possible.

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Aggressive treatment pays off

Recurrences also occur more frequently if treatment has not wholly eradicated depressive symptoms. Therefore, treatment should aim for maximum relief.

It's best to gradually increase the dose of an antidepressant until no further improvement is seen. Preliminary research also supports continuing with the full, therapeutic dose even after you start to feel better, rather than risk taking a lower dose that may be only partially effective. Yet inadequate dosages are a common problem. Primary care doctors who are less experienced with psychopharmacology are often reluctant to increase doses, and people who are uneasy about taking medication may be reluctant to try a higher dose.

Here are some other strategies worth considering in search of a lasting, full recovery:

• switching to a different antidepressant if the first one is not adequately effective

• combining two antidepressants that have different mechanisms of action

• adding a second drug (not primarily an antidepressant) that may augment the effect of the antidepressant you're taking

• combining medications and therapy.

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Keeping up with medication

Journal of the American Medical Association To prevent a relapse, it's important to continue taking your medication even after you feel better. A study from the divided into two groups 150 people with dysthymia or double depression who had responded to treatment with sertraline (Zoloft). Some of these people continued to take the drug, while the rest took a placebo. After 18 months, only 6% of the group taking sertraline had relapsed, compared with 23% of the placebo group.

Most psychiatrists will recommend that you stay on your medication for about a year after a first episode of depression. If you have had several episodes, your doctor will probably recommend maintenance treatment indefinitely.

Is it a relapse or not? When you stop taking an antidepressant, you may experience uncomfortable symptoms as your body readjusts. These might include stomach upset, loss of appetite, or diarrhea; flulike symptoms such as a runny nose, sweating, muscle aches, or fever; and a variety of other symptoms such as tingling, restlessness, trouble sleeping, vivid dreams, fatigue, dizziness, or lightheadedness. Sometimes people also experience mood changes, such as irritability, sadness, anxiety, agitation, or crying spells. It can be difficult to know whether this is a result of stopping the medication or if the original depression is returning. The best way to tell is to wait a short time. Symptoms linked to coming off an antidepressant almost always disappear within several days or weeks. If symptoms of depression continue, however, see your doctor about restarting the antidepressant. Tapering off your medicine slowly can help you avoid this problem. The medications most likely to cause these symptoms are the ones that leave the body rapidly so your doctor may switch you to one that stays in your system longer and then gradually ease you off that one.

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Getting help

Asking for help may seem like the hardest task in the world, especially if you feel exhausted and hopeless. Yet that's just what you need to do if you have symptoms of depression or mania. Even if your symptoms are more vague or you don't know exactly what the problem is, you may still benefit from a doctor's opinion and evaluation. If you feel lost or stuck, or are concerned about a feeling, thought, behavior, or situation, seek help.

The first step is often the hardest. Talk with your doctor about your problems, or get a referral to a mental health professional from your doctor, a friend, or one of the organizations listed in this report (see "Resources"). If you are in a crisis or feel suicidal, immediately call 1-800-SUICIDE for advice or go to your local emergency room.

Regular plans with friends and family members to see a movie or take a walk can keep you from feeling isolated.

Together, you and your doctor or therapist can decide on a treatment plan to alleviate your distress. In addition, the following practical suggestions may help you navigate safely through this difficult time:

• Ask a friend or family member to accompany you to your first appointment to help describe your problem, assist you in getting treatment, or simply offer support.

• Take medications as directed. Don't skip pills or change doses without consulting your doctor. Also, report any side effects right away, and if necessary, talk to your doctor about adjusting your treatment plan.

• Set realistic goals for yourself. Try not to take on more than you can handle.

• Join in activities, and try not to isolate yourself from others. Depending on your personal preferences, attending religious services, having a meal with an understanding friend, or going to a movie, ball game, or concert may help lift your mood.

• Try to exercise regularly or take a daily walk.

• Hold off on making big decisions about moving, changing jobs, getting married, or seeking a divorce until your depression has eased or is under control.

• If you decide to try a "natural" remedy, such as St. John's wort, ask your doctor or pharmacist whether it might interact with any other medication you're taking.

• Friends and family often want to help. Let them.

How to cope when a loved one is depressed, suicidal, or manic Like a pebble thrown into a pond, depression, dysthymia, and bipolar disorder create ripples that spread far from their immediate point of impact. Those closest to people who have these illnesses often suffer alongside them. It's upsetting to see a loved one so distressed, and it's exhausting and often frustrating to deal with the inevitable fallout. But you can do a lot to help a loved one and yourself handle this difficult period. Encourage him or her to get treatment and stick with it. Remind the person about taking medication or keeping therapy appointments. Don't ignore comments about suicide. If you believe your loved one is suicidal, call his or her doctor or therapist. If neither is available, call a local crisis center or emergency room. Care for yourself. Being a caretaker is a difficult job. You may want to seek individual or group therapy. Numerous mental health organizations sponsor such groups (see "Resources") and can also provide you with information on the illness and the latest treatments. Offer emotional support. Your patience and love can make a huge difference. Ask questions and listen carefully to the answers. Try not to brush off or judge the other person's feelings, but do offer hope. Suggest activities that you can do together, and keep in mind that it takes time to get better. Remind yourself that a disease is causing your loved one to act differently or perhaps be difficult. Do not blame him or her, just like you wouldn't if it were chronic physical pain that caused the person to change in certain ways. Try to prevent reckless acts during manic episodes. It's all too common for a person to make poor decisions when manic, so it's a good idea to try to prevent this problem by limiting access to cars, credit cards, and bank accounts. Watch for signs that a manic episode is emerging (see "What are your symptoms?"). Disruption of sleep patterns can trigger an episode, so support your loved one in keeping a regular sleep schedule. Consistent patterns for other activities such as eating, exercising, and socializing may also help.

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Depression, sex, and age

Depression can strike anybody at any age. However, women are more likely than men to suffer from depression. And it's not uncommon for women and men to face depression at different times in their lives and for different reasons. Sex and age can also help determine how someone expresses and copes with symptoms. Treatments vary with age, as well.

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Women

All over the world, depression is much more common in women than in men. In the United States, the ratio is two to one, and depression is the main cause of disability in women. One out of eight women will have an episode of major depression at some time in her life. Women also have higher rates of seasonal affective disorder, depressive symptoms in bipolar disorder, and dysthymia.

Why are women so disproportionately affected? Many theories have been advanced to explain this difference. Some experts believe that depression is underreported in men (see "Men"). But there may also be other, more complex reasons for women's greater vulnerability to depression.

In the United States, approximately 12 million women are affected by depression each year, and one out of eight women will have an episode of major depression at some time in her life.

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Men

Although there is considerable evidence that women are twice as likely as men to become depressed, some researchers question this statistic. They contend that if studies accounted for differences in how men and women express and cope with their emotions, this apparent gap in depression rates would diminish or possibly disappear.

Typically, men are more likely to shy away from talking about their feelings, and doctors may bring up emotional topics less often with men. In addition, many men don't feel comfortable acknowledging the need for help, making them less likely to seek assistance than women are. Men also tend to describe the experience of depression in less intense ways than women do.

Depression in men may be obscured behind a variety of physical complaints, such as low energy, aches and pains, a loss of appetite, or trouble sleeping. Or the problem may come out as substance abuse, anger, or belligerent behavior. Even if other symptoms of depression are present, some men may not feel sad. And if a loved one raises the subject, they may not be willing to admit the possibility that they are depressed. Yet when such men receive treatment for depression, their symptoms often disappear, and in retrospect they may concede that they were, in fact, depressed.

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Children and teenagers

While some people idealize childhood, in reality, children may feel shaken by developmental changes and events over which they have little or no control. Studies show that 2 out of every 100 children and 8 in 100 adolescents have major depression.

While a full-blown depression most often starts in adulthood, low-grade depression, or dysthymia, may begin during childhood or the teenage years. Although an adult has to have depressive symptoms for at least two years before he or she is diagnosed with dysthymia, in children and teens a diagnosis is made after one year. When dysthymia appears before age 21, major depressive episodes are more likely to emerge later in life.

In teens, as in adults, bipolar disorder and depression are clearly connected. As many as 30% of teenagers who experience an episode of major depression develop bipolar disorder in their late teens or early 20s. While rare in early childhood, this disorder occasionally appears in adolescence, especially in cases where a family history of depression exists. Bipolar disorder that emerges during puberty often displays a mixture of high and low symptoms or rapid cycles of highs and lows.

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Older adults

Depression is not a normal part of aging, although many older people and their caregivers think the two go hand in hand. As people age, they do often encounter many familiar sources of depression, including losing loved ones and facing health problems. Still, depression can and should be treated in people of all ages.

Journal of Abnormal Psychology American Journal of Psychiatry About 15% of adults over age 65 have significant depressive symptoms, and about 3% have major depression. But, as noted earlier, the risk of suicide increases with age: The National Institute of Mental Health reports that older Americans are disproportionately likely to die by suicide, and that white men over age 85 have the highest suicide rates in the United States. Two studies further underscore why older people with even minor depressive symptoms need treatment: One, published in the in 2002, found that older adults with signs of depression had diminished immune responses, which may affect their ability to fight off infections or disease. Another, published in the in 2004, found that more depressive symptoms in older adults meant more limitations on daily activity and a greater need for care. People with no depressive symptoms received three hours a week of care on average, those with one to three depressive symptoms had about four hours of care a week, and those with four to eight depressive symptoms needed six hours of care a week.

Journal of the National Cancer Institute Research has also linked depression to cancer and Alzheimer's disease in older people. A long-term study of more than 4,800 men and women over age 70, reported in the , found that those who suffered from chronic depression lasting at least six years had an 88% higher risk of developing cancer. In another study, Dutch researchers followed several thousand seniors over the course of three years. They noted that the risk of developing Alzheimer's or experiencing a decline in mental powers was higher among those who were depressed.

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On the horizon

Our understanding of depression and bipolar disorder has changed radically since the mid-1990s, and we're likely to learn even more in the coming years. Right now, the following avenues of inquiry look promising.

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Glossary

acetylcholine: A neurotransmitter that helps mediate learning and recollection.

adrenal glands: Two glands (one on top of each kidney) that secrete cortisol and norepinephrine.

amygdala: A region of the brain that processes emotionally charged memories.

antidepressant: A drug used to combat depression.

antipsychotic: A drug used to treat psychotic symptoms, such as disordered thoughts, delusions, or hallucinations.

brain imaging: A variety of technologies, such as computed tomography (CT), magnetic resonance imaging (MRI), functional MRI (fMRI), and positron emission tomography (PET), used to examine the structure or function of different regions of the brain.

cognitive behavioral therapy: A form of therapy that aims to correct ingrained patterns of negative thoughts and behaviors.

corticotropin-releasing hormone (CRH): A hormone secreted by the hypothalamus that helps rouse the body when a physical or emotional threat appears.

cortisol: A glucocorticoid, or steroid hormone, released by the adrenal glands and necessary to many basic body functions. This stress hormone is also involved in triggering the "fight or flight" response and similar responses.

dopamine: A neurotransmitter that affects movement and influences thought processes, possibly affecting motivation and reward.

gamma-aminobutyric acid (GABA): A neurotransmitter that may help quell anxiety.

glutamate: A neurotransmitter that may play a role in mood disorders and schizophrenia.

hippocampus: A portion of the brain that plays a central role in processing long-term memories and recollection.

hypomania: A mild mania.

hypothalamic-pituitary-adrenal (HPA) axis: A system that governs a multitude of hormonal activities in the body, including the body's responses to stress.

hypothalamus: A network of nerves above the brainstem that regulates the body's self-maintenance functions (such as blood pressure, temperature, and fluids). It receives signals from elsewhere in the body and secretes hormones that influence the production of other hormones, such as cortisol and thyroid hormone.

interpersonal therapy: A form of therapy that concentrates on illuminating and ironing out problems in current relationships.

monoamine oxidase inhibitors (MAOIs): Antidepressant medications that act by preventing the breakdown of the monoamines serotonin and norepinephrine.

neuron: A nerve cell.

neurotransmitters: Chemicals such as serotonin or norepinephrine that convey messages across the gap (synapse) between adjoining neurons.

norepinephrine: Sometimes called noradrenaline, this neurotransmitter plays a role in the regulation of mood, anxiety, and drive.

pituitary gland: A pea-sized organ located below the brain; it secretes adrenocorticotropic hormone.

psychodynamic therapy: A form of therapy that focuses on how life events, desires, and close relationships lead to conflict, symptoms such as anxiety or depression, and difficulty in managing life's tasks.

seasonal affective disorder (SAD): Sadness and depression that's brought on by a lack of exposure to sunlight. SAD usually appears in the fall or winter and subsides in the spring.

selective serotonin reuptake inhibitors (SSRIs): Antidepressants that block the reuptake of serotonin into the neurons that released it, leaving more serotonin available to nerve cell receptors.

serotonin: A neurotransmitter that helps regulate sleep and appetite, mediate moods, and inhibit pain.

thalamus: A central brain structure that relays sensory information.

tricyclic antidepressants (TCAs): A class of drugs that is thought to work by increasing the availability of norepinephrine and serotonin to nerve cell receptors.

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Resources

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Organizations

American Foundation for Suicide Prevention www.afsp.org 120 Wall St., 22nd Floor New York, NY 10005 888-333-2377 (toll free)

This nonprofit organization supports research on suicide. It also offers information on suicide and its prevention as well as support for survivors.

American Psychiatric Association www.psych.org 1000 Wilson Blvd., Suite 1825 Arlington, VA 22209 703-907-7300

This medical society's Web site offers fact sheets, booklets, and news articles on a wide range of mental health issues. It also includes a listing of psychiatric societies throughout the United States that can provide referrals to psychiatrists.

American Psychological Association www.apa.org 750 First St., NE Washington, DC 20002 800-374-2721 (toll free)

The organization's Web site has information and helpful publications on mental illness and many other topics for psychologists, parents, teens, and others. It also carries news on psychology and offers referrals to psychologists in the United States and Canada.

Depression and Bipolar Support Alliance www.dbsalliance.org (formerly the National Depressive and Manic Depressive Association) 730 N. Franklin St., Suite 501 Chicago, IL 60610 800-826-3632 (toll free)

This nonprofit organization provides information, advocacy, and support for people with depression and bipolar disorder, as well as their family members. The Web site has detailed information on suicide prevention strategies for anyone struggling with thoughts of suicide or for concerned family and friends.

National Alliance on Mental Illness (NAMI) www.nami.org Colonial Place Three 2107 Wilson Blvd., Suite 300 Arlington, VA 22201 800-950-6264 (toll free)

This advocacy group offers information and support groups for people coping with a variety of mental illnesses and for families of people with such illnesses.

National Center for Complementary and Alternative Medicine nccam.nih.gov NCCAM Clearinghouse P.O. Box 7923 Gaithersburg, MD 20898 888-644-6226 (toll free)

This government agency, part of the National Institutes of Health, offers a wealth of publications and fact sheets on a variety of health problems, including mental illness. It also sponsors valuable research on complementary and alternative medicine.

National Institute of Mental Health www.nimh.nih.gov 6001 Executive Blvd., Room 8184, MSC 9663 Bethesda, MD 20892 866-615-6464 (toll free)

This government agency, part of the National Institutes of Health, sponsors research on mental illness. It offers a wide array of free publications. The Web site has educational segments on anxiety and depression, news on studies, and information about clinical trials.

National Mental Health Association www.nmha.org 2001 N. Beauregard St., 12th Floor Alexandria, VA 22311 800-969-6642 (toll free)

This nonprofit organization supports mental health research, provides advocacy, and offers information on a variety of mental health topics, including depression. The Web site has discussion boards and a free, confidential screening test for depression.

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Review Date: 2008-04-01