Depression

Symptoms & Causes

What are some symptoms of depression?

Depression can take various forms. It can be obvious–with symptoms such as sadness, irritability, crying easily, and feeling incapable of joy–or it can be more vague, with features like change in appetite, lack of focus, fatigue, headache, and abdominal pain. Sometimes all of these symptoms occur together, but at other times they happen in isolation. It can take time to identify depression, particularly when there’s not an obvious cause or when the symptoms are strictly physical.

What causes depression? Is it genetic?

Depression is often triggered by a life event. When this happens, it is referred to as situational depression (also called adjustment disorder). If a person experiences a life event that impacts them in a negative way, a period of grief is to be expected. Symptoms of grief are much like symptoms of depression. But if grieving extends beyond a reasonable period of time or if the symptoms are out-of-proportion to what would be expected, that pattern is more consistent with situational depression.

For example, it’s normal to grieve after a break-up, but if a person can’t leave home and isn’t engaging in day-to-day activities two years after the end of the relationship, then we would consider that person to be situationally depressed.

Sometimes, symptoms of depression occur without any obvious triggering event, and research does seem to suggest that there is a biological component to this sort of depression. There is still much to be learned about the genetic transmission of mental health disorders, but what we do know is that depression appears to have some heritability. In other words, if you have relatives who are depressed, your chances of experiencing depression are higher.

Of course, just because someone doesn’t seem to have an obvious trigger for depression doesn’t mean that there isn’t an underlying cause (repressed childhood trauma is an example). It’s usually a combination of environment and genetics that contributes to the development of depression, but sometimes one entity plays a more significant role than the other. It’s also important to note that some medical conditions can cause symptoms of depression–hypothyroidism and Parkinson’s disease are two examples.

Types of Depression

There are different types of depression, such as postpartum, premenstrual, seasonal affective, chronic, and situational. What are the similarities and differences among their symptoms and how they’re treated?

Depressive symptoms vary by individual, not by depression type. For instance, someone who is prone to the more physical symptoms of depression–like fatigue and decreased appetite–will experience those symptoms regardless of whether they have perinatal or seasonal depression.

Treatment recommendations may vary–light therapy would be an important recommendation for seasonal affective disorder, but not necessarily for perinatal depression–but there is also some overlap (e.g., talk therapy is a great option for any type of depression).

Here are some of the more common types of depression:

• Major Depressive Disorder: Severe, persistent low mood lasting for at least 2 consecutive weeks (often, months to years).
• Dysthymia: Mild, persistent low mood, lasting for at least 2 years
• Perinatal Depression: Formerly called postpartum depression, it’s now clear that pregnancy-associated depression can occur both during and after pregnancy. Perinatal depression is thought to stem from the neuropsychiatric effects of hormonal fluctuation, as well as the psychosocial impact of pregnancy and childbirth.
• Premenstrual Dysphoric Disorder: PMDD is a severe version of premenstrual syndrome (PMS). Some women experience extreme symptoms of depression, even suicidality, for the luteal phase of their menstrual cycle (that is, during the 1-2 weeks prior to menses).
• Seasonal Depression (Seasonal Affective Disorder, SAD): Because exposure to sunlight is closely linked to mood, depression can be more prevalent in the darker months of fall and winter, as well as in geographies with less sunlight.
• Situational Depression (also known as Adjustment Disorder with Depressed Mood): Depression that is triggered by a life event, usually loss.

What’s the difference between depression and anxiety?

Depression and anxiety have some similar features, and the two often go hand-in-hand. A person who experiences depression may have moments or even extended periods of anxiety, while someone who suffers from an anxiety disorder may struggle with bouts of depression.

The primary differences are in symptomatology. Symptoms of depression generally include low energy, fatigue, lethargy, lack of motivation, and mental fogginess. Anxiety commonly manifests as nervousness, inability to sit still, racing thoughts, rapid heartbeat, and jitteriness.

Despite the distinctive symptoms, initial therapeutic approaches are the same for both depression and anxiety. Therapy is the mainstay of treatment. When medicine is a consideration, first-line medications for both depression and anxiety are selective serotonin reuptake inhibitors (SSRIs), which allow serotonin–the feel-good brain chemical–to remain in the nervous system longer. Other interventions that have been shown to alleviate and prevent both depression and anxiety are adequate sleep, exercise, and meditation.

Diagnosis

How is depression diagnosed?

While there are no specific lab tests to diagnose depression, there are a variety of evidence-based assessments that can be used, the most common of which is the PHQ-9. Although a person might already be aware of the signs and symptoms of depression and know that they are suffering from it, sometimes it’s less obvious, particularly if it’s a first episode.

Either way, the PHQ-9 is a helpful tool not only for diagnosis, but also for assessment of severity and monitoring of progress after treatment is initiated. The nine-question evaluation, administered by a healthcare professional, results in a numeric score that correlates with a category of symptom intensity, ranging from minimal to severe. If it’s not clear to an individual whether they are contending with depression, a consultation with a primary care provider is a good place to start.

Some symptoms of depression can be very physical (fatigue, appetite change, mental fogginess). How do you know if it’s depression or something else?

If there is no obvious reason for an individual to be depressed, it can take time to reach a diagnosis of depression, particularly if a person’s symptoms are purely physical (e.g., fatigue, low energy, change in appetite). Often, a healthcare provider will evaluate for other diagnoses, such as hypothyroidism or anemia. There are also a number of physical health conditions that independently increase one’s risk for depression, including heart disease and other chronic inflammatory disorders.

If other possible causes of a person’s symptoms are ruled out, a healthcare provider usually proceeds with a depression evaluation and may try treatment to see if that helps. If treatment is helpful, then a diagnosis of depression is considered confirmed.

Treatment

There are so many treatment options for depression - what’s best?

Research shows that the most effective treatment option for most types of depression is therapy. There are a number of different types of therapy–talk therapy, cognitive behavioral therapy, music therapy, art therapy, group therapy–to name just a few. Often, therapists employ a combination of therapy types to treat their patients. Of course, if someone is in imminent danger from severe depression with suicidal thoughts, it’s important to seek help right away–a reliable resource is the Suicide Prevention Lifeline, with counselors available online or by phone (1-800-273-8255) around-the-clock.

The most important aspect of therapy is the therapist-patient relationship. If a person doesn’t feel comfortable with their therapist or if the therapy provided doesn’t resonate, then the treatment is not likely to be effective. Trying to find the right therapist can feel intimidating. There are a number of variables to consider, including therapeutic approach, experience, and cost. There are some helpful websites like www.psychologytoday.com that list thousands of therapists, sortable by a variety of filters.

Keep in mind that an effective therapeutic relationship is more reliant on individual fit than on the practitioner’s credentials. Proper training is essential, but degree type (MD, DO, PsyD, PhD, PMHNP, MSW, LPC, LMHC) doesn’t necessarily indicate that a therapist will be the right fit for someone. It’s usually apparent within the first visit or two whether a particular therapist will be the right person to work with on a regular basis. It can take time. Meeting a few different therapists before finding the right one is not unusual.

For severe depression that is not resolving with therapy, the addition of medication is a consideration. There are many different antidepressant medications to choose from. The most commonly prescribed as firstline treatment are selective serotonin reuptake inhibitors (SSRIs), which work by increasing serotonin levels in the brain. Serotonin is a natural mood-lifter. SSRIs don’t necessarily make more serotonin, but they slow the brain’s processing of it, allowing serotonin to saturate the nervous system for longer than it otherwise would.

Because it’s difficult to predict which SSRI might be most effective for an individual, there is often a period of trial-and-error involved in determining the best medication for someone. SSRIs can take a while (up to 6 weeks) to achieve full effect, but people often notice mild improvement after a couple of weeks. MDs, DOs, and psychiatric nurse practitioners can prescribe medication; a therapist who does not have one of these degrees will refer to a colleague who can provide medication management, if medication is warranted.

The goal with pharmaceutical treatment is to help a person feel like themselves again, not numb or unable to experience a full range of emotions. Common side effects of antidepressants are dry mouth, nausea, insomnia or fatigue, change in appetite, and decreased sex drive. Some of these are transient, only lasting during the first few weeks of initiation, while others may persist. Side effects can be minimized by using the lowest effective dose possible. Not all SSRIs cause side effects for all individuals.

SSRIs are not the only medications available for the treatment of depression. Other classes of antidepressants include serotonin-norepinephrine reuptake inhibitors (SNRIs), medications that impact dopamine activity (bupropion), monoamine oxidase inhibitors (MAOIs), mood stabilizers, antipsychotic medicines, and tricyclic antidepressants. For severe major depression that does not improve with medication, a treatment option that can be extremely effective is electroconvulsive therapy (ECT). Unlike the shock treatment depicted in movies, ECT is administered under anesthesia and does not elicit pain or distress. For some people, it results in rapid, marked improvement in symptoms of depression.

There are a number of Integrative treatments for depression that offer potential benefits. Supplement options include St. John’s Wort, omega-3 fatty acids, MSM, 5-HTP or other amino acids, SAMe, rhodiola, and ashwagandha (or other adaptogenic, stress-modulating herbs). Traditional Chinese medicine treatments, such as acupuncture and herbal blends, have been used for thousands of years in Asia. Other Integrative approaches include bodywork, eye movement desensitization and reprocessing (EMDR), hypnotherapy, biofeedback, and yoga.

Prevention

What can be done to prevent depression?

Depression is not always preventable, but there are lots of ways to optimize mental health and mitigate the risk of depression. The most effective way to develop and maintain a healthy mind and body is to focus on the basics: adequate sleep, good nutrition, regular exercise, and meditation.

Perfection in all of these areas is not the goal–it can be challenging to do any of them well, let alone all of them. Trying to tackle too much at once almost always backfires. Sustainable lifestyle improvement should be approached gently; it takes months, even years, of practice to implement lasting change. Furthermore, there are varying interpretations of how much of a good thing is enough. Here’s a rough outline of what to aim for:

• Sleep: Eight hours is right for some but research suggests that sleep requirement varies per individual. One way to evaluate what’s right for you is to set aside a few consecutive mornings that don’t require an alarm–go to bed at a consistent, reasonable hour and see what time you wake up naturally, feeling refreshed.

• Nutrition: The average American diet includes a high proportion of processed foods, which tend to cause abrupt changes in blood sugar, leading to erratic energy and mood. Incorporating whole foods and minimizing processed ones allows for a more stable blood sugar level throughout the day. Supplementation with a multivitamin, vitamin D, and B vitamins sometimes help if diet and lifestyle do not provide adequate recommended intake. A Mediterranean or anti-inflammatory diet provides a useful framework for meeting nutritional needs.

• Exercise: The benefits of exercise are not limited to the well-known endorphin release from a single workout. Emerging research suggests that regular exercise may reshape brain architecture over time, supporting improvements in mental wellness. It’s unclear exactly how much exercise is required for these long-term benefits, but 150 minutes per week is a good goal. If it’s been a while since you’ve last exercised, start with 15-20 minutes of walking 1-2 days per week. In the beginning, it’s most important to establish the habit. Once you’ve grown accustomed to exercise as a part of your regular schedule, you can gradually increase the intensity and duration.

• Meditation: Meditation is increasingly recognized as a powerful way to improve mental health. As with physical exercise, starting small is the key to implementing a sustainable practice. Even one minute of meditation daily can help to establish a habit. Over time, it naturally becomes easier to access and maintain a mental state of stillness. Ten minutes of meditation per day can be enough to confer benefit, though long-term practitioners of meditation often devote much longer periods of time (an hour or more) to their daily practice. Meditation can provide a sense of grounding and connection. Connection to others, to the natural world, a higher power, or a sense of purpose enhances the human experience for many. Loss of these connections or failure to develop them often contributes to a sense of loneliness or absence of richness in life. Meditation is one way of fostering meaningfulness. Other examples include socializing, caring for a pet, volunteering, engaging in a spiritual practice, and spending time in nature.

Useful Links

Suicide Prevention Lifeline (1-800-273-TALK)

Major Depression: Statistics (National Institute of Mental Health)

Depression Symptoms and Warning Signs (HelpGuide)

Behavioral Health Treatment Services Locator (Substance Abuse and Mental Health Services Administration)