What is depression?
The word depression is used to describe a range of moods - from low spirits to a severe problem that interferes with everyday life. People who are experiencing severe or 'clinical' depression are not just sad or upset. The experience of depression is an overwhelming feeling which can make someone feel quite unable to cope, and hopeless about the future. If you are depressed you may lose your appetite and have difficulty sleeping. You can feel overwhelmed by guilt, and may even find yourself thinking about death or suicide. There is often an overlap between anxiety and depression, in that if you are depressed you may also become anxious or agitated. Sometimes it is difficult to decide whether someone is responding 'normally' to difficult times, or has become clinically depressed. A rough guide in this situation is that, "if your low mood affects all parts of your life (home, work, family, social activities), last for two weeks or more, and brings you to the point of thinking about suicide" (BMA 1998) then you may be experiencing clinical depression and you should seek some kind of help.
Who becomes depressed?
Anyone can become depressed. Approximately one person in six experiences depression of some kind in the course of their lifetime and 1 in 20 experiences clinical depression. At any one time, about one in 10 people will have some symptoms of depression. Of course, people who are depressed do not always seek help and even if they do, they may not always be diagnosed as depressed, so these figures are only estimates. People from all backgrounds, ages and cultures can experience depression, although people vary in how they express their difficulties. In many Western countries women are more likely then men to be diagnosed with depression, but this is partly because men are less likely to report their depression and seek help.
Children and young people:
About 2% of children under 12 experience depression. This rises to about 5% for teenagers. A particular worry is the rise in the numbers of young men who attempt suicide, which is often the result of depression.
Depression in both women and men is often linked to life changes or to loneliness. About 10% of women experience postnatal depression in the weeks following childbirth. Social factors which can make people more at risk of becoming depressed include loss of employment, bereavement and problems with relationships.
People over 65 seem to have a slightly greater risk of depression. This risk gets much higher in people over 85yrs. It can be particularly difficult to recognise depression in older people because they are less likely to talk about feeling sad or low, and more likely to talk about physical problems such as loss of energy or difficulty sleeping. This means that GPs, family and friends may not understand how they are feeling. In older people it appears that depression is less likely to 'lift' without help, particularly if they are severely depressed. This may explain why older depressed people have a high suicide rate, particularly men over the age of 75 years.
Depression can also be confused with the effects of other health problems, which are more common in later life. People who are depressed often report feeling confused and having difficulty in thinking and remembering things. In older people it is important to find out whether these problems are due to depression or to the development of dementia - for example in Alzheimer's Disease or following a stroke.
How is depression diagnosed?
When deciding whether to give someone a diagnosis of depression, professionals look for the following key symptoms:
- Depressed or irritable mood most of the day, nearly every day
- Loss of interest or pleasure
- Changes in weight or appetite
- Sleep problems
- Tiredness and loss of energy
- Feeling guilty or worthless
- Difficulty in concentrating or making decisions
- Thoughts of death or suicide
A diagnosis of depression should be given if you experience at least five of these symptoms over a two-week period. However, everybody's experience of being depressed is different. For example, some people are severely depressed for a relatively short time while others have milder depression over a number of years, and there are other patterns in between. Even if the depression seems mild it is still important, and can have a big impact on someone's life and ability to enjoy life.
We also need to understand that there are differences in the way people describe their feelings. For example, some people use words such as 'sad' or 'low' to describe feeling depressed, whereas other people describe their feelings in terms of their body, such as 'a pain in my heart'.
Are there different kinds of depression?
The following are some specific types of depression which have been identified:
Bipolar disorder (Manic depression)
About 1% of the population will experience bipolar disorder at some time in their lives. A diagnosis of bipolar disorder means that you have both 'high' and 'low' mood swings, along with changes in thoughts, emotions and physical health. The mood swings are normally more extreme than everyday ups and downs. This kind of depression is sometimes also referred to as manic depression. Most people with bipolar disorder have their first episode of depression in their late teens or early twenties, and without treatment it is very likely to recur.
[For further information on depression as part of bipolar disorder contact the Manic Depression Fellowship - see list of addresses at the end of this page]
About 10 to 15% of women experience postnatal depression in the first year after having a baby. They may be unusually tearful, anxious or irritable, and may also find it difficult to play with their babies and respond positively to them. Although most women feel 'up and down' in the first few days of childbirth - the so-called 'baby blues' - because of rapid hormone changes, postnatal depression is very different from this and lasts longer. It is probably due to a mixture of biological, psychological and social factors, and women are particularly at risk of post-natal depression if they do not have a supportive partner or family to help them. If someone seems to be showing signs of postnatal depression their Health Visitor should be able to assess them and provide appropriate help. Most women with postnatal depression benefit greatly from supportive counselling and from talking to other women who have been through a similar experience.
[For further information on postnatal depression contact the Association for Post-Natal Illness - see list of addresses at the end of this page]
Seasonal Affective Disorder (SAD)
Some people describe feeling depressed regularly at certain times of the year. Usually this kind of depression starts in the autumn or winter, when daylight is reduced. Because of this a popular treatment for SAD is the use of special bright light (see below). A key feature of this kind of depression is the desire to sleep more and eat carbohydrate foods. People experiencing this kind of depression may be helped by specially designed light boxes.
[For further information contact the SAD Society - see list of addresses at the end of this page]
What causes depression?
There are many possible causes of depression. You may have an increased risk of experiencing depression because of your particular biological make-up. On the other hand, depression is also related to what is happening in your life, and the kind of support you receive from others. Past experiences which may be difficult or traumatic, such as losing a parent when very young, can affect your ability to cope with difficult situations.
Is depression inherited?
There is some evidence that depression seems to run in families, but there is no single gene which causes depression. A family history of depression may increase the risk, but this may be because of difficulties the family has in coping, and it certainly does not mean that depression is inevitable. Genes seem to be more important than childhood experiences in determining the risk of bipolar disorder.
Is depression caused by changes in the brain?
We know that depression is associated with changes in the activity of certain brain chemicals, known as 'neurotransmitters', which affect our mood and thinking. These chemicals, such as serotonin, are also affected by factors such as activity and exercise. Drug treatment aims to restore 'normal' levels of neurotransmitter activity (see below).
What about stress?
An episode of depression can be 'triggered' by stressful things that happen in our lives, particularly events involving a loss of some kind - such as unemployment, leaving home, death of a family member or friend. Even an apparently happy event can also bring a sense of loss; for example, parents can feel they have 'lost' their son or daughter when they get married, even if they are very happy for them. If you have had to cope with a lot of changes or stressful events, one more may seem like the 'last straw'. Older people may have to cope with repeated losses, and are particularly likely to experience bereavement. A study of people in their 70s found that those whose husbands or wives had recently died were four times more likely to be depressed than those who were still married. Some widows and widowers still had high levels of depression two years after the death of their spouse. Men living alone after the death of their wives seem to be particularly at risk for depression.
Styles of thinking and coping
Everyone has to deal with sadness, disappointment and loss at some time in their life. But whether this leads to depression can depend on your ability to adopt a hopeful approach to life. People who are depressed tend to think about bad experiences in ways that make them even more difficult to manage. If you have had bad experiences in the past, which you were unable to control, you develop a 'hopeless' way of thinking. Feeling 'trapped' in a difficult situation or experiencing a feeling of humiliation can also lead to negative thinking and depression. But...
Health & illness
We all tend to feel miserable when we are ill. But long-term health problems, which prevent someone from leading their usual life, may lead to depression. People who lose their eyesight or hearing can become depressed, as can people with heart disease, chronic lung diseases, and illnesses which prevent them from getting about, such as Parkinson's disease or stroke. Family and friends can help a lot, in by helping people find new activities or interests following illness.
Is it 'normal' to become depressed as you get older?
It is usual to experience sadness, grief, and disappointment when we encounter difficulties or losses. Some of these life events may become more common with age, for example, when children move away, family members die, or friends become ill or disabled. Health or financial problems can undoubtedly ali to the burdens of age. However, it is important that severe (clinical) depression is recognised, so that people can get the help they need. Many people find that there are positive benefits of growing older, such as having more free time, being able to take up hobbies or spend time with grandchildren, or getting away from a stressful working life. It is therefore wrong to assume that depression in older people is a 'normal' reaction to growing older.
What can we do to reduce the risk of depression?
There are a number of things we can do for ourselves which may prevent depression, help us cope with mild or moderate depression, or help us recover from periods of depression.
Having someone to turn to for support is very important when coping with difficulties. Some people build up a strong network of friends and relatives whom they can talk to. But others may become isolated, particularly if they also have no employment or other activity outside the home. People who are already depressed usually find it very difficult to be sociable, and this can make them feel more depressed. So it is important for a person with depression to be encouraged to keep in contact with friends and find someone to talk to when they are feeling low. Research with women in London found that those who had someone to confide in were less likely to become depressed when coping with difficulties than women who had no one to turn to.
Activity & Exercise
Research has shown that being more active is associated with lower levels of depression. Outdoor activity seems to be particularly important in staving off depression in older men. Exercise programmes are now being used to help people who are depressed, with promising results. For example, a study in Australia reported that people who were depressed or anxious benefited significantly from attending an exercise class, and an American study claimed that exercise was as effective as antidepressant drugs. However not all research has shown such dramatic results, and it is likely that exercise works best for those people who enjoy it most. People who are physically active or take regular exercise not only benefit from changes in the brain chemicals which affect mood, but also from the feeling that they are actively doing something to improve their life. Exercise and activity can also bring important social contact for people who are isolated.
Recent research has suggested that people who are depressed may have low levels of certain essential fatty acids (Omega-3), which are found in fish oils. This may be partly due to the fact that in most industrialised countries our intake of Omega-3 fatty acids has been falling, while our intake of saturated fatty acids has increased. Some people may be particularly affected by these changes in diet. It has therefore been suggested that people with depression should change their eating habits, for example eating more oily fish such as sardines, or should take fish oil supplements which are rich in Omega-3 fatty acids, especially EPA, alongside their prescribed medication. This may be particularly helpful for people diagnosed with bi-polar disorder.
Many people are interested in using complementary therapies to relieve depression. There is some evidence that the herbal medicine known as St John's Wort (Hypericum perforatum) can help many people with mild to moderate depression. However we do not yet know whether it is effective in treating more severe depression. Before taking St John's Wort check with your doctor or pharmacist especially if you are taking other kinds of medication, for example for heart disease, epilepsy, asthma or migraine, as St John's Wort may affect how these drugs work. People have also reported benefits from relaxation techniques, listening to music, and acupuncture, but more research is needed before we can be certain how effective these treatments are.
As explained above, one of the risk factors for depression is the feeling that, whatever you do, you cannot prevent bad things happening or you cannot improve your situation. An important step to good mental health is therefore to find situations or activities where you can feel that you have some control over what happens and can make a difference to your life and others. This helps to guard against the kind of 'hopelessness' which is associated with depression. Activities that involve making a 'fresh start' have been shown to help people recover from long-lasting depression. Similarly, learning to set yourself small or manageable goals can give you a sense of achievement and make you feel better.
Older people in particular may feel that they are no longer valued as employees or needed as parents, so it is important to find new ways of being 'in control' of one's life. Helping other people - for example through voluntary work - is one good way of feeling useful and valued.
There are a number of self-help books, guides, and software programmes which can help you to learn ways of coping with mild to moderate episodes of depression. Some of these are listed at the end of this page. Bear in mind that although many people have found these helpful, everybody is different! If you do not find them helpful, or if your depression is more severe, you should ask for more specialist help. Some people find it very helpful to talk to others who have been through similar experiences. Some of the organisations listed at the end of the page can put you in contact with other people , individually or in groups.
Where to get help
There are a number of places where you can go to get help, as follows: General practitioners (GP): this is a good place to start. Your GP can help you to find the right type of help. This may include medication, or a referral to another agency for other forms of treatment such as 'talking treatments'. GP surgeries will also hold a range of leaflets and information about local services.
Community mental health centres
In most cases, you will require a referral from the GP in order to be eligible for treatment. Professionals such as psychologists and counsellors within these centres will be able to offer a range of treatments as outlined below. Most mental health centres will carry out an initial assessment. This involves a discussion whereby both you and the worker will identify what your needs are, and possible steps for managing depression. This process will enable both of you to decide which service and type of help is most suitable.
Your local office will be able to direct you to a range of services. Telephone numbers and addresses will be in the telephone directory. Local mental health associations or voluntary organisations: some of these operate telephone helplines, others you may visit personally, usually without a formal referral. You can find out about these organisations from local directories of services, your local library, or telephone directory. Availability of these service varies across areas.
Details of these groups can be found in telephone directories and from local advice and information centres. Some addresses are also given at the end of this page.
Citizens Advice Bureaux (CAB)
Details of your nearest CAB can be found by looking in a local telephone directory. Advisers will be able to tell you more about local services and how to access them. In some cases, they may be able to provide some basic information, or even make initial contacts with other agencies on your behalf. Community Health Councils (CHC): local CHCs will have information on local services. Their contact numbers will be in your local telephone directory.
What treatments are there for depression?
Anti-depressant drugs act by increasing the activity of those brain chemicals which affect the way we feel. Anti-depressants are thought to help between 60 and 70% of people with depression. The following kinds of drugs may be prescribed:
Examples of these are dothiepin, imipramine, and amitryptyline. They are prescribed for moderate to severe depression and take up to two weeks to start working. Some tricyclic antidepressants can cause drowsiness, so talk to your doctor about this. Other possible side-effects include blurred vision, a dry mouth, constipation, sexual problems, and weight gain. Side-effects can usually be reduced by changing to a different brand or by starting at a lower dose.
SSRIs and SNRIs
Newer antidepressant drugs (SSRIs and SNRIs) target specific chemical 'messengers' in the brain. The most well-known SSRI is fluoxetine (Prozac) but there are several other brands. These newer drugs are popular because they tend to have fewer side effects than older drugs. However some people become more anxious and restless when taking them and there have been reports of some people becoming aggressive. As with all drugs, any unusual reactions should be discussed with a doctor straightaway. For example, venlafaxine (Efexor) can cause a skin rash which should be reported to a doctor immediately.
Lithium carbonate may be prescribed to people with bipolar disorder as a way of stabilising their mood swings. High levels of lithium in the blood are dangerous so anyone taking lithium must have regular blood tests. Other mood stabilisers include carbamazepine.
What about coming off medication?
If you are prescribed drugs for depression you will probably be advised to take them for at least six months - or longer if you have a previous history of depression. Older people may have to carry on taking drugs for longer than younger people, to reduce the risk of another episode of depression.
You may experience withdrawal effects if you stop taking anti-depressant drugs, particularly if you stop suddenly. These effects can include headache, nausea, dizziness and even hallucinations. Always consult your doctor before stopping taking anti-depressants. Do not stop taking medication suddenly as the withdrawal effects may be severe.
It is important to feel confident that you can discuss your medication with your GP or pharmacist. Family and friends can help by encouraging the person with depression to report any unpleasant side-effects, especially when a new or different drug is prescribed. There are also special helplines which will give you general advice on medication (see contacts list)
Children and young people
Tricyclic drugs have been used with children but they seem to be less effective than with adults. The newer SSRIs have not yet been adequately tested with children.
As people grow older they are increasingly likely to be prescribed drugs for medical conditions. If drugs for depression are alied there can be unexpected side-effects, such as dizziness and confusion. Sometimes just taking too many different drugs can produce symptoms of depression. It is quite common for older people with memory problems to forget to take their drugs, particularly if they have lots of different drugs to take. It is a good idea to ask the pharmacist to supply the pills in a special container, which has separate compartments for each day of the week, or each time of day.
People diagnosed with dementia (such as Alzheimer's disease) often experience depression, but anti-depressant drugs seem to be less effective for them than for other people of the same age. They may also experience more side-effects from medication, such as loss of appetite or increased confusion. Anti-depressant drugs should only be prescribed to people in nursing homes if they are actually depressed. They should not be used as a way of keeping people quiet or easier to manage.
CBT is a type of 'talking' treatment. It is based on the fact that the way we feel is partly dependent on the way we think about events (cognition). It also stresses the importance of behaving in ways which challenge negative thoughts - for example being active to challenge feelings of hopelessness. Although it may sound like common sense, CBT is more than just positive thinking. If you are depressed, a CBT therapist will carry out an individual assessment and use questions and exercises to help you see your situation in different ways and to build up coping skills. It is important that CBT is delivered by someone who has been properly trained, such as a clinical psychologist or specially trained nurse. You also find it useful to have someone to help with the activities such as 'homework' exercises.
Research suggests that CBT can be effective for people with both severe and moderate depression. A combination of drugs and CBT can also produce good results. CBT may also reduce the risk of the person experiencing another period of depression. CBT has also been used successfully with children and adolescents, particularly those with moderate levels of depression.
Older people are less likely to be offered talking treatments such as CBT, even though they are just as likely to benefit from them as younger people.
Interpersonal Therapy (IPT)
Interpersonal therapy focuses on people's relationships and on problems such as difficulties in communication, or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT but more research is needed.
Counsellors are trained to help people think about the problems they are experiencing in their lives and find new ways of coping with difficulties. They give support and help people find their own solutions, rather than offering advice or treatment.
Electroconvulsive therapy (ECT)
ECT is a controversial treatment which is intended only to be used for people with severe depression who have not responded well to medication or other treatments. The person receiving ECT is given an anaesthetic and drugs to relax their muscles. They then receive an electrical 'shock' to the brain, through electrodes placed on the head. Most people are given a series of ECT sessions. Some people say that ECT is very helpful in relieving their depression, although others have reported unpleasant experiences, including memory problems.ECT should not normally be used unless other approaches have been tried first, and it should not be used with people who have not given their consent.
There is some evidence that older people may be given ECT rather than offering alternative forms of treatment. This may be because older people take longer to respond to drug treatment, or because they are less confident about refusing treatment. It is therefore important that adequate time is given for drugs or other treatments to be effective before deciding to use ECT. Another important consideration is that people having ECT need a general anaesthetic, which carries more risks in older people. ECT should not be considered when people have severe heart or lung disease.
Depression is a distressing experience but there are many kinds of help available. Sadly people do not always get the help they need, sometimes because they feel too hopeless about their situation to ask. After reading this page you may like to discuss it with your GP or talk it through with family or friends. You may also like to contact one of the organisations or helplines listed below. Remember that people DO recover from an episode of depression - especially when they ask for the help they need.
Association for Post Natal Illness
145 Dawes Road, Fulham, London SW6 7EB United Kingdom, Tel: +44 (0)20 7386 0868 (Hours: 10am - 2pm Mon-Fri and 24hr answerphone), Fax: +44 (0)20 7386 8885, Email: email@example.com, Website: www.apni.org. Promotes research into postnatal illness and educates professional bodies regarding this illness; runs a countrywide network of volunteers who have had and recovered from PNI, and who support a mother currently suffering on a one to one basis throughout the illness and recovery period.
35 Westminster Bridge Road, London SE1 7JB, United Kingdom. Tel: +44 (0)20 7633 0557. Fax: +44 (0)20 7633 0559. Email: firstname.lastname@example.org, Website: www.depressionalliance.org. A UK charity offering help to people with depression, run by sufferers themselves. Provide publications on various aspects of depression and a written advisory service offering support and understanding. Produce an extensive quarterly newsletter, which includes information and suggestions from members about how best to manage depression. Their annual National Depression Campaign aims to increase awareness of depression and its symptoms, people who may be depressed to seek help. They also have offices in Scotland and Wales.
Fellowship of Depressives Anonymous (FDA)
Box FDA, Ormiston House, 32-36 Pelham Street, Nottingham NG1 2EG, United Kingdom. Tel: +44 (0)1702 433 838 (9am-9pm every day, this number is not based at the office address). Self-help/mutual aid organisation for people who have, or are liable to have, depression and their family and friends. Some local groups, Pen Friend Scheme and publications.
The Manic Depression Fellowship (MDF)
Castle Works, 21 St Georges Road, London SE1 6ES, United Kingdom. Tel: +44 (0)20 7793 2600. Fax: +44 (0)20 7793 2639. Email: email@example.com, Website: www.mdf.org.uk. Self-help organisation for people with manic depression, their relatives and friends. Has a network of 150 support groups. Quarterly journal, factsheets and publications available. Telephone for free information pack.
Mind, Granta House
15-19 Broadway, London E15 4BQ, UK. Tel: +44 (0)20 8519 2122. MindinfoLine: 0845 766 0163 (Mon-Fri, 9:15am-5:15pm). Email: firstname.lastname@example.org, Website: www.mind.org.uk. Mind works for everyone in emotional distress, campaigning for rights and developing locally based services. Mind's national Info Line covers all aspects of mental health including advocacy, treatments and therapies.
PO Box 989, Steyning BN44 3HG, United Kingdom. Website: www.sada.org.uk. Informs the public and health professionals about SAD and supports and advises people with SAD. Produces a newsletter and other publications, hold meetings, has a network of contacts and local groups. They also hire out light-boxes for treatment and raise money for research. Send a SAE for details.
Website: www.mhf.org.uk. As the UK's leading charity concerned with both mental health and learning disabilities, the Mental Health Foundation plays a vital role in pioneering new approaches to prevention, treatment and care. The Foundation's work includes: allocating grants for research and community projects, contributing to public debate, educating and influencing policy makers and health care professionals.
Published by The Mental Health Foundation and reproduced here with their permission ©2000