Depression

adultsian h. gotlib, karen l. kasch

children and adolescentsjudith semon dubas,anne c. petersen

ADULTS

Major depression is a syndrome that affects 15 to 20 percent of the population. It is among the most prevalent of all psychiatric disorders. Moreover, twice as many women than men comprise the 15 to 20 percent of the population who will experience a clinically significant episode of depression at some point in their lives. Major Depressive Disorder, the diagnostic label for a clinically significant episode of depression, is characterized by at least a two-week period of persistent sad mood or a loss of interest or pleasure in daily activities, and four or more additional symptoms, such as marked changes in weight or appetite, sleep disturbance, restlessness or slowing of thoughts and movements, fatigue, feelings of guilt or worthlessness, concentration difficulties, and thoughts of suicide. Although there are clearly difficulties in attempting to study depression in different cultures (Tsai and Chentsova-Dutton 2002), the prevalence of depression varies widely across the world. In general, Asian countries, such as Japan and Taiwan, have the lowest documented lifetime prevalence rates of depression (both approximately 1.5%); poorer countries like Chile have the highest rates (27%); the United States and other Western countries have intermediate lifetime prevalence rates of depression (Tsai and Chentsova-Dutton 2002). It is interesting to note that studies have shown that Mexicans born in Mexico have lower rates of depression, while those born in the United States have rates the same as non-Hispanic whites (Golding, Karno, and Rutter 1990; Golding and Burnam 1990). In general, the more acculturated Mexican-Americans are, the less likely they are to experience depression. However, those with more acculturative stress (e.g., coping with a move from being high status in Mexico to being lower status in the United States) tend to experience more depression than those with less acculturative stress (Hovey 2000).

The relatively high rates of depression have led the World Health Organization Global Burden of Disease Study to rank this disorder as the single most burdensome disease in the world in terms of total disability-adjusted life years (Murray and Lopez 1996). More importantly, depression not only has a high prevalence rate, but also has a high rate of recurrence. Over 75 percent of depressed patients have more than one depressive episode (Boland and Keller 2002), often developing a relapse of depression within two years of recovery from a depressive episode. This high recurrence rate in depression suggests that there are specific factors that increase people's risk for developing repeated episodes of this disorder. In attempting to understand this elevated risk for depression, investigators have examined genetic and biological factors, and psychological and environmental characteristics, that may lead individuals to experience depressive episodes.

Some forms of depression have a strong genetic influence. Depression has been shown to run in biological families; indeed, having a biological relative with a history of depression increases a person's risk for developing an episode of depression. Furthermore, twin research has consistently and reliably demonstrated that major depression is a heritable condition (e.g., Kendler and Aggen 2001). Research using broad definitions of depression suggests that men and women have different heritabilities for depression, with genetic factors proving more etiologically important for women than for men (Kendler and Aggen 2001). Gaining a better understanding of this difference in heritabilities may help to elucidate the reasons underlying the higher rates of depression in women than in men.

Although genetic factors are important, they do not fully explain the etiology of depression. For example, there are sets of identical (monozygotic) twins in which one is affected with depression and the other never becomes depressed. Because monozygotic twins have identical genetic makeups, these differences must be due to factors that the twins do not share. Some of these factors are biological (but not genetic). There is abundant evidence that biology can affect mood. For example, thyroid problems can often mimic depression and cause weight changes, sad mood, and other symptoms of depression. Similarly, investigators have demonstrated some drugs or medications (e.g., reserpine) can induce a depression-like syndrome, whereas other medications (e.g., antidepressants) are effective in alleviating depressed mood. These medications generally affect the neurotransmitters implicated in depression. Biological factors can also affect the risk for depression. For instance, obstetrical complications seem to increase the risk of developing depression later in life (Fan and Eaton 2000; Preti et al. 2000). In addition, because in virtually every culture women are at greater risk for depression than are men (cf. Nolen-Hoeksema 1990), it is likely that something about the biology of being female, such as hormonal functioning, may make depression more likely to occur.

There are also psychosocial influences in the development of depression. Some research suggests, for example, that a childhood history of abuse or neglect can put an adult at greater risk for depression (e.g., Bifulco, Brown, and Adler 1991). Moreover, there is evidence that a history of abuse may be related to suicidal thoughts and behavior both in patients and nonpatients, above and beyond the effects of having a diagnosis of depression (Read et al. 2001; Molnar, Berkman, and Buka 2001). Furthermore, social support (e.g., from friends or family) can mitigate depression, whereas a lack of support may increase the severity or length of a depressive episode (George et al. 1989; Goering, Lancee, and Freeman 1992). Finally, there appears to be a robust link between stressful life events (e.g., divorce, bankruptcy) and the onset of major depression, suggesting that such events may play a role in the etiology of some major depressive episodes (Stueve, Dohrenwend, and Skodol 1998). Recent studies have examined the impact of befriending as an intervention for women with chronic depression, and have found that the addition of such social support had a positive impact on the depression, further bolstering the importance of social support in depression (Harris, Brown, and Robinson 1999).

Temperamental factors have been found to increase people's risk for developing depression. For instance, there is a great deal of evidence linking neuroticism to depression (e.g., Duggan et al. 1995; Kendler et al. 1993). In fact, high levels of neuroticism have been found not only to be associated with current depression, but also to persist in people following recovery from their depressions. Some investigators have drawn on these data to suggest that neuroticism may be present prior to the first onset of depression, and may represent a vulnerability marker or risk factor for developing depression (Duggan et al. 1995).

Finally, there may be specific patterns of thinking that elevate people's risk for the development of depression. Research has demonstrated that certain cognitions or cognitive styles are strongly related to depression. For example, according to the reformulated learned helplessness model (Abramson, Seligman, and Teasdale 1978), people who believe that negative events result from stable, global, and internal factors are more likely to become depressed than are individuals who do not hold these views. For instance, if a person believes that he failed a math test because he is bad at math, rather than attributing the failure to the difficulty of the test or his having had a bad day, then he is attributing his failure to an internal factor. If he then says that he is bad at school more generally and has always been, then he is making stable and global attributions as well, putting him, according to this model, at increased risk for becoming depressed. Similarly, Aaron Beck (1976) has posited that individuals who attend to negative stimuli more readily than to positive stimuli, and who have dysfunctional beliefs about loss and failure (e.g. that others never fail, or that they should never fail), are also likely to become depressed. Although these negative cognitive styles may be longstanding and appear to be a part of someone's personality, it is still unclear whether these cognitive patterns cause depression, are a consequence of depression, or have a more complex relationship to this disorder (Gotlib and Abramson 1999).

Depression and Interpersonal Relationships

Depression in adults can often have a negative impact on interpersonal relationships. Depressed people evaluate their social skills negatively, reporting that they do not enjoy, and are not very adept at, socializing (Davis 1982; Lewinsohn et al. 1980). Independent observers have documented that depressed people have fewer social skills than nondepressed individuals (Segrin 2000). The relationships of depressed people are often characterized by low intimacy, poor communication, and withdrawal, characteristics that may lead to rejections and disappointments. Indeed, depression in individuals can lead others around them to feel irritability, anger, and fatigue; depressed people have been found to exhibit a high level of dependency on others, or to withdraw from others, both of which can put a strain on interpersonal relationships.

Late-twentieth-century research indicates that depression also adversely affects the quality of relationships with spouses and children. For example, investigators have found the interactions of married couples in which one spouse is depressed to be characterized by less cooperation and more angry exchanges than is the case among couples in which neither spouse is depressed (Davila 2001; Goldman and Haaga 1995). Not surprisingly, depression in marriage has been shown to be strongly associated with distress and disruptions in marital relationships; indeed, the rate of divorce among individuals who have experienced clinical depression is significantly higher than is the case among nondepressed individuals (e.g., Wade and Cairney 2000).

Given the high level of marital distress and discord associated with depression, it is not surprising to learn that the children of depressed parents have themselves been found to exhibit greater emotional and somatic symptomatology, and to have more school, behavioral, and social problems, than have children of nondepressed parents. Children of depressed parents have also been found to be at elevated risk for developing psychopathology (see Gotlib and Goodman 1999, for a review of these literatures). Several lines of research have emerged trying to understand the mechanisms underlying the elevated levels of psychopathology among children of depressed parents (Goodman and Gotlib 1999). Whereas a number of investigators have examined the genetic transmission of risk for depression from parent to child (e.g., Wallace, Schneider, and McGuffin 2002), other researchers have focused on aspects of the relationships between depressed parents and their children. For example, when they are depressed, adults are less effective at disciplining their children and are more likely to exhibit frustration and anger or withdraw and behave in a rejecting manner when they cannot achieve their desired outcomes with their children. Children of depressed parents may also model their parent's behavior and either act out and exhibit anger, or become isolated and withdrawn. They may feel unloved and find that they only get attention when they misbehave, which will tend to increase the amount of misbehavior. Depressed parents may come to rely to heavily on their children to perform tasks that they have become unable to carry out. Depressed parents may also rely too heavily on their children for emotional support when their marital relationship becomes strained. In this context, a depressed parent may share information that a child is unable to handle emotionally, such as thoughts of suicide or hopelessness.

Treatment of Depression

Depression is a treatable disorder. Because there are a variety of methods for treating depression, people who experience depression have several choices with respect to the type of treatment they choose to undertake. Treatments that focus on the depressed individual alone include pharmacotherapy (e.g., antidepressant medication) and psychotherapy (e.g., cognitive therapy, behavior therapy, or social skills training). Depressed people who are married may choose from these individual approaches to treatment, or they may undertake marital or family therapy for depression. Regardless of which form of treatment a depressed person chooses, it is important that the treatment has been demonstrated empirically to be effective in reducing depressive symptoms.

Although it may seem counterintuitive to treat marital problems in order to alleviate depression, there is evidence in support of the efficacy of this type of treatment, particularly in distressed marriages. Indeed, there are several different forms of marital and family therapy that are effective in the treatment of depression. For example, in maritally distressed couples, marital therapy has been found to be effective in treating depression in the context of marriage. K. Daniel O'Leary, Lawrence Riso, and Steven Beach (1990) asked wives in distressed marriages to identify which came first, the marital problems or their depression. In couples who reported that marital discord preceded the onset of depression, the wives reported that the marital distress was an important cause of their depression. This raised the possibility that marital therapy would be a way of targeting the perceived causes for depression. In fact, studies have demonstrated that marital therapy is as effective as individual cognitive-behavioral therapy in alleviating depressive symptoms of spouses in distressed marriages. Moreover, patients receiving marital therapy have been found to report higher marital satisfaction than do patients receiving cognitive-behavior therapy (Jacobson et al. 1991; O'Leary and Beach 1990). Steven Beach, Mark Whisman, and K. Daniel O'Leary (1994) suggest that behavioral marital therapy is an effective intervention for a specific subgroup of married depressed patients.

Interpersonal therapy (IPT) for depression usually takes approximately twelve weeks and also focuses on the current marital distress. Although IPT bears some relationship to psychodynamic treatments that preceded it, its focus is different. Instead of dealing with past conflicts and unconscious material, this treatment emphasizes current problems and concerns. This form of treatment was adapted in the late twentieth century to work with geriatric populations by including certain kinds of concrete help in the treatment (e.g., obtaining transportation for the patient to attend sessions), flexibility in the length of sessions, and acknowledging the different life circumstances of older adults that may make some solutions less feasible or desirable (e.g., divorce after a long marriage; see Gotlib and Schraedley 2000 for a review of IPT for depression).

Another form of treatment for depression that has an interpersonal focus is behavioral family therapy. Like interpersonal therapy, behavioral treatment focuses on current problems. Behavioral treatment emphasizes concrete and specific behavior changes, along with skills training as needed. Early in the treatment, families in which a member is depressed are educated about depression's symptoms and consequences. The therapist underscores both the legitimacy of the disorder and the importance of treatment compliance, both for the person suffering from depression and for the family. In addition, families are taught better communication skills, including how to compromise, negotiate, manage anger, constructively express feelings, and listen empathically. Families are also provided with problem-solving skills training, and learn to concretely define their goals and generate more solutions to achieve those goals.

Finally, cognitive-behavioral family therapy has also been found to be effective in the treatment of depression. As with behavioral treatment, cognitive-behavioral family therapy also offers skills training in communication and problem solving as needed. In addition, the therapist models appropriate behavior: for example, parental discipline as part of skills training in parenting. Here, too, the focus is on current problems and concerns. Although cognitive-behavioral treatment is similar to behavioral therapy in its emphasis on current behavior and training of skills, this form of treatment is based on the notion that people's thoughts about events and actions lead them to make specific attributions about the event or action. This process may lead them to have overly negative expectations of their relationships and interpersonal interactions. Individuals with these negative cognitive schemas are also believed to filter their experience through the lens of their expectations, perceiving more of their interactions as negative than is actually the case. One of the therapist's primary tasks is to help the family identify attributions and the irrational beliefs that underlie them. The therapist demonstrates to the family how these thoughts and beliefs can affect their behavior and the behavior of those with whom they come into contact. Once the therapist has elucidated the relationship between the cognitions and behavior, cognitive restructuring can begin. Cognitive restructuring involves the therapist helping the family to understand the irrationality of the original maladaptive cognitions. According to cognitive-behavioral theory, by changing people's attitudes and beliefs, cognitive restructuring leads to behavior change.

Depression and Culture

Depression is a heterogeneous condition that may call for different types of treatment depending on the specific marital context in which the depressed person lives. Depression also occurs, of course, in many different cultural contexts. As with any disorder, depression can interact with culture and values; consequently, treatments need to be culturally sensitive and aware. Moreover, these different values mean that specific treatments or recommendations may be more useful and effective in some groups and, in fact, may even be contraindicated in others. For example, in African-American families, there is generally less of an emphasis on culturally defined gender roles than is the case in Caucasian families. Employment for women from African-American families has been found to be helpful to these women and their families, whereas employment showed fewer benefits for Caucasian women and their families, at least among older adults (Cochran, Brown, and MacGregor 1999). Therefore, clinicians may find that helping African-American women gain access to employment opportunities would be a useful intervention, whereas Caucasian women may receive fewer benefits from such help.

In Asian cultures, in which there is a greater focus on the interdependence of family members and connection with other people within the larger culture, depression may manifest in different ways than in the West and may therefore respond to different types of treatment. Because of Asians' greater cultural emphasis on social connection, what are viewed as symptoms of depression in the West may be interpreted more as interpersonal difficulties in these cultures. In addition, Asians may focus more on somatic difficulties than on emotional symptoms, perhaps in part because they make fewer mind/body distinctions in their culture than do Westerners. Therefore, "depression" in those cultures may be expressed and experienced more through physical than emotional symptoms. This may also be related to the fact that emotional problems are typically viewed as more stigmatizing in Asian cultures than they are in the West. Because of this greater stigma, Western treatments of discussing feelings and troubles are often contraindicated with Asian patients because this may exacerbate emotional pain and the shame, rather than alleviating suffering. Finally, Asians generally experience greater family and social connections and support than do people in Western cultures. This seems to be somewhat protective against depression and rates of depression in Asian countries such as Japan, China, and Taiwan are lower than in the Western world.

Latin/Hispanic cultures also place a greater emphasis on family than do many other Western cultures. Although the social support from family is protective, poverty and lack of resources continue to plague many Latino communities. Latino families living in the United States may find themselves relatively isolated from American culture and opportunities and, consequently, at greater risk for depression and other difficulties. Given the findings that lower acculturation is associated with more depression (e.g., Hovey 2000), it would seem important to aid less assimilated families in accessing resources and finding ways to become acculturated while maintaining their original cultural identity. In addition, it is crucial that clinicians attempt to remove the linguistic, cultural, and practical barriers to treatment faced by many minority populations. Finally, clinicians need to be sufficiently culturally knowledgeable to understand certain symptoms in context. For example, in Puerto Rican culture, dissociative states may be a normal part of spiritual practice, though these states would generally be considered psychopathological in mainstream U.S. culture (Tsai et al. 2001). Clinicians who can recognize culturally normative practices and differentiate them from pathology, and who develop culturally appropriate treatments, will be the most likely to be successful in alleviating their patients' distress.

See also:Children of Alcoholics; Chronic Illness; Depression: Children and Adolescents; Development: Self; Developmental Psychopathology; Grief, Loss, and Bereavement; Health and Families; Postpartum Depression; Power: Marital Relationships; Self-Esteem; Stress; Suicide; Therapy: Couple Relationships

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ian h. gotlib
karen l. kasch

CHILDREN AND ADOLESCENTS

The sadness that characterizes depression is similar at all ages but is most upsetting to adults when observed in children. Depression is characterized by feelings of sadness, fatigue, and a general lack of enthusiasm about life. It can be of short or long duration, of low or high intensity, and can occur at any stage of development. Up until the 1970s there was considerable disagreement about whether depression could occur before the onset of formal operational thought, a cognitive ability that emerges in adolescence. Later debates have shifted to determining the specific age at which children are able to identify and label feelings related to depression, and recent findings suggest that by five or six years of age children are capable of doing so (Ialongo, Edelsohn, and Kellam 2001). The use of parent reports has allowed for the identification of depressive disorders among preschoolers, and additional work has focused on identifying young children who are at risk for depression because they have one or more relatives with a mood disorder (Cicchetti and Toth 1998).

Depression Classifications

The classification and investigation of depression typically focuses on: depressed mood, depressive syndromes, or clinical depression (or depressive disorders). Each approach reflects differences in assumptions concerning the nature of depression and denotes different levels of depressive phenomena (Petersen et al. 1993; Cicchetti and Toth 1998).

Depressed mood. Research on depressed mood has focused on depression as a symptom denoted by feelings of sadness, unhappiness, or the blues lasting for an unspecified period of time. It is differentiated from normal sadness by the absence of positive affect, a loss of emotional involvement with other persons, objects, and activities, and negative thoughts about oneself and the future (Fombonne 1995). Self-report measures are most often used with older children and adolescents; parent and/or teacher reports are typically used for younger children.

Depressed mood occurs in about one-third of all youth at any point in time, and ranges from 15 to 45 percent among adolescent samples. Results from the few studies that have charted depressed mood across the adolescent years suggest that it peaks around the ages of fourteen and fifteen and then attenuates slightly (Petersen, Sarigiani, and Kennedy 1991). Reliable gender differences do not exist until adolescence, when girls are more likely to experience depressed mood than boys.

Depressive syndromes. Depressive syndromes involve sets of symptoms that have been shown to occur together. Behavior problem checklists, completed either by children/adolescents or parents/teachers, are the main source of identification. These checklists usually include either severity or frequency ratings and consist of items such as sadness, moodiness, sleep disturbances, feelings of worthlessness, guilt, and loneliness. Most research examining depressive syndromes has used a cutoff score corresponding to the ninety-fifth percentile in nationally representative samples. In comparing the mean scores on the Anxious/Depressed Syndrome of the Child Behavior Checklist across twelve cultures (ages ranged from six to seventeen years), Alfons Crijnen and colleagues (1999) found Germany, the Netherlands, Sweden, and Thailand to be lower on average, whereas Greece, Israel, Puerto Rico, and the United States were above average, with Australia, Jamaica, Belgium, and China being average. Girls obtained higher scores than boys across all cultures.

Clinical depression. Clinical depression is more severe and lasts longer than depressive mood or syndromes and has a major impact on daily living. Clinical depression is identified by categorical diagnoses, such as those described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994) or the International Classification of Diseases (ICD-10) (World Health Organization 1996). Most often these diagnoses are made through individual interviews with a clinical psychologist. According to the DSM-IV, two forms of depression have been identified: Major Depressive Disorder (MDD) and Dysthymic Disorder (DD).

The diagnosis of MDD requires the presence of at least five of nine symptoms during the same two-week period, with one of the symptoms being depressed mood (dysphoria) for most of the day nearly every day or loss of interest and pleasure (Kolvin and Sadowski 2001). Irritable mood in children and adolescents may be substituted for depressed mood. The other possible symptoms include: significant weight change (in children, the failure to make expected weight gains), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, diminished ability to concentrate or indecisiveness, and recurrent thoughts of death, suicidal ideation, or suicide attempt. The symptoms are not due to direct psychological effects of a substance, a general medical condition, or bereavement. An episode of MDD in children lasts, on average, about eleven months, with recovery generally taking about seven to nine months (Kovacs and Sherill 2001). Estimates of the point prevalence of MDD range from 0.4 to 2.5 percent for children and from 0.4 to 8.3 percent for adolescents (Birmaher et al. 1996; Verhulst et al. 1997). The estimated lifetime prevalence of MDD for adolescents is 15 to 20 percent, a rate comparable to that for adults (Harrington, Rutter, and Fombonne 1996).

The diagnosis of DD requires the experience of depressed mood for most of the day, for most days for at least two years (Kolvin and Sadowski 2001). For children and adolescents irritable mood and a duration of at least one year are allowed as alternative criteria. Two of six additional symptoms (poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, poor self-esteem, difficulty concentrating or making decisions, and feelings of hopelessness) are also required.

There appears to be a trend for both an increased rate of depression across generations, and an earlier onset of major depressive disorder, with more onsets occurring during adolescence than previously (Fombonne 1995). A recent review of the gender differences in rate of clinical depression concluded that prior to puberty boys are anywhere from two to five times more likely to exhibit depression than are girls, whereas after age thirteen this difference shifts to girls with depression occurring at least twice as frequently in girls and women as in boys and men (Angold and Costello 2001)

Additional co-occurring problems with depression. Studies on both community and clinical samples report that anywhere from 7 to 51 percent of depressed children and adolescents have multiple psychiatric disorders, with anxiety and conduct or disruptive behavior disorders as the most common co-occurring disorders (Kovacs and Sherrill 2001). Anxiety disorders often precede depressive conditions. Eating disorders and drug and alcohol use often co-occur with depressive symptoms. Adolescents with affective disorders have a higher than normal risk of suicide.

Causes

There is no single cause for depression and any single risk factor rarely results in depressive outcomes. Rather, the structure of biological, psychological, and social systems over an individual's development need to be considered (Cicchetti and Toth 1998).

Heredity. Although there is no conclusive evidence that there exists a specific, single gene for depression, there is evidence that some families have an inherited vulnerability to depression. Close relatives of depressed people have a 15 percent chance of inheriting major depression. An identical twin with a depressed twin is 67 percent more likely to be depressed. A child having one depressed parent is six times more likely to develop depression than a child without a depressed parent and the risk for a child to develop depression increases to 40 percent if both parents are depressed. The parents and extended family members of depressed children are not only more likely to exhibit a higher incidence of depression but also found to have higher levels of anxiety, substance abuse, and antisocial behavior (Cicchetti and Toth 1998). Although this association is partially a result of heredity, the environment that family members share also contributes to depressive symptoms (Rende et al. 1993). The fact that many depressed children promptly recover when hospitalized, even when no other treatments are administered, lends additional credence to the role the family may play in a child's depression (Cicchetti and Toth 1998). Additionally, relapse of depression after being released from in-patient psychiatric care is confined primarily to children who return home to an environment characterized by high emotional overinvolvement, criticism, and hostility (Asarnow et al. 1993).

Parental depression. As noted above, children having one or two clinically depressed parents are more vulnerable to developing depression than children without a depressed parent. In addition, more severe and chronic parental depression is associated with greater impairment in children (Goodyer 2001). Several possible mechanisms for the increased vulnerability to depression for children of depressed parents, besides direct hereditary transmission of depression, have been proposed. Most research in this regard has focused on mothers and how they interact with their children, although more recent work is including fathers. A parent struggling with his or her own depression may not be able to provide adequate responsiveness and care to children as the depression may interfere with the ability to react flexibly and creatively to the normative challenges that parenting entails (Kaslow, Deering, and Racusin 1994). Children of depressed mothers are at greater risk for an insecure attachment and for disruptions in emotional regulation (Cicchetti and Toth 1998; McCauley, Pavlidis, and Kendell 2001), which, in turn, increases a child's vulnerability for depression. Compared to nondepressed mothers, depressed mothers are more likely to use withdrawal, conflict avoidance, or overcontrolling strategies rather than negotiation to cope with child noncompliance (McCauley, Pavlidis, and Kendell 2001). Depressed mothers and fathers tend to be more hostile and irritable when interacting with their children, and the marital relationship itself often is characterized as dysfunctional and conflictive. Moreover, families with a depressed parent experience increased and persistent stressors, further taxing a parent's ability to cope constructively. Hence, not only is child nurturance disrupted but also a depressed parent serves as a role model for depressive thinking (McCauley, Pavlidis, and Kendell 2001). Moreover, the child becomes increasingly exposed to stressful life events that are not under his or her control, further increasing vulnerability to feelings of helplessness, hopelessness, and depression. Thus, children of depressed parents are at increased hereditary risk for depression, are more likely to experience disruptions in both physical and emotional relations with parents, have parental role models for depressive thinking, and are more likely to experience stressful life events and conflict. Together these findings underscore how children of depressed parents are exposed to a variety of risk factors that increase their vulnerability for depression.

Family context. Compared to families of nondepressed children, families of depressed youth have higher levels of marital and parent-child conflict, low levels of family cohesion, and diminished overall social support. Regardless of ethnicity, social class, or parents' marital status, parents who are accepting, firm, and democratic have adolescents who report less depression (Steinberg et al. 1991; Herman-Stahl and Petersen 1996). Longitudinal studies have also demonstrated that adolescents with warm family relations are less likely to become depressed several years later (Petersen, Sarigiani, and Kennedy 1991).

Dante Cicchetti and Sheree Toth (1998) propose that a vulnerability to depression may begin in infancy if there is an insecure attachment to primary caretakers. Infants who are insecurely attached are more likely to have less than optimal emotional regulation and expression, and as these infants grow into young children significant others are perceived as unavailable or rejecting while the self is perceived as unlovable. These perceptions may contribute to a proneness to self-processes that have been linked to depression (e.g., low self-esteem, helplessness, hopelessness, and negative attributional biases). When combined with additional environmental stressors these self-processes may contribute to a modification of hormonal and brain processes that further increase vulnerability.

Brain and hormonal processes. Research on biological disregulation during depression focuses on the hypothalamic-endocrine and neurotransmitter systems. As noted in the Surgeon General's report on mental health (1999), some of the primary symptoms of depression, such as changes in sleep patterns and appetite, are related to functions of the hypothalamus. The hypothalamus, in turn, is closely linked to the pituitary gland. Increased rates of circulating cortisol and hypo- and hyperthyroidism, each associated with pituitary function, are established features of adult depression. Research on the hypothalamic-endocrine link involved in childhood and adolescent depression focuses on the hypothalamic-pituitary-adrenal (HPA), hypothalamic-pituitary-gonadal (HPG), and hypothalamic-pituitary-somatotropic (HPS) axes, all of which are related to growth processes and pubertal change (Brooks-Gunn, Auth, Petersen, and Compas 2001). In each of these axes the hypothalamus secretes a releasing hormone that triggers the pituitary to release a stimulating hormone, which, in turn, then stimulates the secretion of an additional hormone by the particular gland in question (adrenal, gonadal, thyroid). This hormone is then released into circulation, inhibiting the hypothalamus and pituitary to produce more releasing and stimulating hormones (Brooks-Gunn et al. 2001). Variations from normal patterns of coritsol and dehydroepiandrosterone (both from the HPA axis), prolactin (from the HPG), and growth hormone (from the HPS axis), have been observed among depressed children and adolescents (Dahl et al. 2000; Schulz and Remschmidt 2001).

At the neurotransmitter level, differences in serotogenic, cholinergic, noradrenic, and dopaminergic systems have all been associated with depression (Brooks-Gunn et al. 2001; Sokolov and Kutcher 2001). Whereas early research focused on deficiencies or excesses in neurotransmitter substances, current research now focuses on the functioning of the neurotransmitter systems with respect to the storage, release, reuptake, and responsiveness (Sokolov and Kutcher 2001). New research is examining the interaction between the hypothalamic-endocrine and neurotransmitter systems. However, as noted by Jeanne Brooks-Gunn and her colleagues (2001), less certain is whether changes and deficits in these systems are causes, correlates, or a result of depression. Nevertheless, once a depressive episode occurs, biological disregulation follows, further influencing behavior, thought, mood, and physiological patterns.

Cognitive factors. Attributional bias and coping skills are the two main cognitive factors investigated with respect to understanding depression. Considerable research has focused on the pessimistic attributional biases that are prevalent among depressed adults. A person with this bias readily assumes personal blame for negative events, expects that one bad experience will be followed by another, and that this pattern will endure permanently. Individuals who think this way have a tendency to cope with situations more passively and ineffectively than those without this bias. Among children, this attributional style is related to depression after the age of eight years; prior to this, childhood depression is primarily linked to negative life events (Nolen-Hoeksma, Girgus, and Seligman 1991).

Adaptive coping skills are important in order to regulate negative emotions when unpleasant and challenging events occur. Problem-focused coping refers to how an individual responds to the demands of a stressful situation in terms of active efforts to do something about the problem. Emotion-focused coping, in contrast, refers to the individual's attempts to control the emotion experienced. One form of emotion-focused coping is rumination: the tendency to focus repetitively on feelings of depression and their possible causes without taking any actions to relieve them. Another form is avoidant coping: the tendency to withdraw from or avoid stressors or to deny their existence. Emotion-focused coping such as rumination and avoidant coping have been linked to depression in adults, adolescents, and children (Herman-Stahl and Petersen 1999; Nolen-Hoeksma 1998).

Gender Differences

Most theories concerning gender differences have focused on explaining the female preponderance during adolescence and adulthood. Males and females appear to have different coping styles: males distract themselves, whereas females ruminate on their depressed mood and therefore amplify it (Nolen-Hoeksma 1998). Most young adolescents are faced with significant changes in every aspect of their lives: pubertal development, cognitive maturation, school transition, and increased performance pressures in academics. For many adolescents these events are stressful. Girls experience more challenges during adolescence compared to boys, including more negative life events, simultaneous changes in pubertal development and school transitions, making them more vulnerable to depression (Petersen, Sarigiani, and Kennedy 1991). Not only are differences in challenges and coping important but the hormonal changes that accompany pubertal development may also make girls more vulnerable (Angold, Costello, and Worthman 1998). Thus, it now appears that a combination of factors, including less effective coping styles, more challenges, and hormonal changes, may help to explain the gender differences in depression during adolescence.

Treatment

Treatments for depression in children and adolescents generally include three forms: pharmacological, psychotherapy, and a combination of the two. Unlike studies on adults, methodologically sound investigations on the relative effectiveness of each type of therapy on youth are only just beginning to be conducted. Thus, most findings are based on a few studies and therefore need to be interpreted cautiously.

Pharmacological. The drugs most commonly used for treating depression in children and adolescents are available in three major types: the monoamine oxidase inhibitors (including phenelzine and tranylcypromine), the tricyclic antidepressants (including lofepramine, imipramine, and nortriptyline) and the recently developed selective serotonin and serotonin-noradrenergic re-uptake inhibitors (including fluoxetine, paroxetine and venlafaxine) (Schulz and Remschmidt 2001). Although virtually all medications found to be effective for adult depression have been tested with children, systematic studies with clear results are rare, and superiority of antidepressant medication over placebos for children and adolescents has not been reliably demonstrated (Kovacs and Sherrill 2001; Schulz and Remschmidt 2001). Therefore, antidepressant medications should only be prescribed for children and adolescents when: symptoms are so severe that they prevent effective psychotherapy; symptoms fail to respond to psychotherapy; and the depression is either chronic/recurrent, nonrapid bipolar, or psychotic (Schulz and Remschmidt 2001). Selective re-uptake inhibitors are the initial antidepressant of choice, although the presence of other symptoms such as impulsivity, suicide, or attention deficit hyperactivity disorder (ADHD) may require alternative medications (Schulz and Remschmidt 2001).

Psychotherapy. Studies of psychosocial interventions for depression among youngsters have traditionally included clinically diagnosed children, children classified as having a depressive syndrome, or youngsters deemed at risk for depression based on elevated scores on depressive symptom checklists. Controlled psychotherapy trials on clinically depressed youth typically include short-term cognitive behavioral therapy (CBT) delivered in individual or group format (Kovacs and Sherrill 2001). Cognitive behavioral therapy is based on the premise that depressed individuals have distortions in thinking concerning themselves, the world, and their future. Thus, therapy focuses on changing or preventing these distortions (cognitive restructuring), and also includes training in social skills, assertiveness, relaxation, and coping skills. Of the seven clinical studies reported to date, 35 to 90 percent of the youths recovered, with higher rates of success for experimental therapies than the control conditions (Kovacs and Sherrill 2001). Although only two studies included a parent component as part of the treatment condition, including the parent component did not improve outcomes. Interventions targeted at nonclinical but at-risk youth identified in school settings have had even more favorable results. Seven of eight studies reported decreases in depressed mood and syndromes. One demonstrated long-term effects of the intervention in reducing the likelihood for developing clinical levels of depression. These promising results highlight the beneficial effects of early identification and prevention efforts. Additional studies are needed to clarify how parents and other family members may be included in treatment programs.

According to Maria Kovacs and Joel Sherrill (2001), clinically referred depressed youth usually experience a disruption to the parent-child relationship. Because depressed children and adolescents are either unwilling or unable to verbalize their affective experience, parents, in turn, may withhold emotional support, guidance, and expressions of affection. Based on their work and that of others, Kovacs and Sherrill suggest that the most appropriate treatment of depressed juveniles should include structured, goal-directed, or problem-solving oriented interventions that focus on symptom reduction, enhancement of self-esteem, and social/interpersonal skill development. In addition, involvement of the parents or primary caretakers is essential and should occur at two levels. First, parents should be assessed to determine if they themselves suffer from a form of emotional or mental disorder. Those who are positively identified should receive treatment. Second, parents should be engaged as agents of change in treatment of their own children, including some sessions explicitly focused on the depressed child's needs and concerns.

See also:Attachment: Parent-Child Relationships; Child Abuse: Physical Abuse and Neglect; Child Abuse: Psychological Maltreatment; Child Abuse: Sexual Abuse; Childhood, Stages of: Adolescence; Children of Alcoholics; Chronic Illness; Conduct Disorder; Depression: Adults; Development: Self; Developmental Psychopathology; Grief, Loss, and Bereavement; Eating Disorders; Health and Families; Interparental Conflict— Effects on Children; Interparental Violence—Effects on Children; Self-Esteem; Stress; Suicide

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judith semon dubas anne c. petersen

Depression

Definition

Depression, also known as depressive disorders or unipolar depression, is a mental illness characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.

Description

Everyone experiences feelings of unhappiness and sadness occasionally. However, when these depressed feelings start to dominate everyday life without a recent loss or trauma and cause physical and mental deterioration, they become what is known as depression. Each year in the United States, depression affects an estimated 17 million people at an approximate annual direct and indirect cost of $53 billion. One in four women is likely to experience an episode of severe depression in her lifetime, with a 10–20% lifetime prevalence, compared to 5–10% for men. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.

There are two main categories of depression: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities in which they once took pleasure, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide. In children, major depression may appear as irritability.

While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, nondepressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem, fatigue, trouble concentrating, and feelings of hopelessness.

Depression also can occur in bipolar disorder , an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Causes & symptoms

The causes behind depression are complex and not yet fully understood. While an imbalance of certain neurotransmitters, the chemicals in the brain that transmit messages between nerve cells, is believed to be key to depression, external factors such as upbringing (more so in dysthymia than major depression) may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence, a pattern of low self-esteem and negative thinking may emerge, and from that, a lifelong pattern of depression may follow. A 2003 study reported that two-thirds of patients with major depression say they also suffer from chronic pain .

Heredity seems to play a role in who develops depression. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals predisposed or prone to depressive disorders, but environmental circumstances may often trigger the disorder.

External stressors and significant life changes, such as chronic medical problems, death of a loved one, divorce or estrangement, miscarriage, or loss of a job also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.

Major depressive episode

Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable, rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:

• Significant change in weight
• insomnia or hypersomnia (excessive sleep)
• psychomotor agitation or retardation
• fatigue or loss of energy
• feelings of worthlessness or inappropriate guilt
• diminished ability to think or to concentrate, or indecisiveness
• recurrent thoughts of death, or suicidal and/or suicide attempts

Dysthymic disorder

Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70% of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders, social phobias , and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis, AIDS, hypothyroidism, chronic fatigue syndrome, Parkinson's disease , diabetes, and postcardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.

Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years), or one year or more for children:

• under or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or trouble making decisions
• altered libido
• altered appetite
• altered motivation
• feelings of hopelessness

Diagnosis

The guidelines for diagnosis of major depressive disorder and dysthymic disorder are found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV ). In addition to an interview, several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, social worker, psychiatrist, or psychologist.

Treatment

A variety of alternative medicines have proven to be helpful in treating depression. A recent report from Great Britain emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise programs, and watchful waiting before subscribing antidepressant medications for mild depression. Chocolate, coffee, sugar, and alcohol can negatively affect mood and should be avoided. Essential fatty acids may reduce depression and boost mood. Expressing thoughts and feelings in a journal is therapeutic. Aromatherapy , particularly citrus fragrance, has had a positive effect on depression. Psychotherapy or counseling is an integral component of treatment because it can find and treat the cause of the depression.

Psychosocial therapy

Psychotherapy explores a person's life to bring forth possible contributing causes of depression. During treatment, the therapist helps the patient to become aware of his or her thinking patterns and how they originated. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem solving and coping skills.

Cognitive-behavioral therapy assumes that the patient's faulty thinking is causing the current depression and focuses on changing thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them, and then retrains the patient to recognize the thinking and react differently to it.

Chinese medicine and herbals

The principle of treatment of depression involves regulating qi, reducing phlegm, calming the mind, and promoting mental resuscitation. The Chinese medicine Bai Jin Wan (White Metal Pill) is used to treat depression (5 g twice daily). A practitioner may prescribe a variety of treatments—including lifestyle changes—depending on the type and severity of the depression.

There is some evidence that acupuncture is a helpful treatment for depression. One double-blind study found that patients who received acupuncture specific for depression were significantly less depressed than control patients who had either nonspecific acupuncture or no treatment.

St. John's wort (Hypericum perforatum ) is the most widely used antidepressant in Germany. Many studies on the effectiveness of St. John's wort have been performed. One review of the studies determined that St. John's wort is superior to placebo and comparable to conventional antidepressants. In early 2000, well designed studies comparing the effectiveness of St. John's wort versus conventional antidepressants in treating depression were underway in the United States. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll shoed that about 41% of 15,000 science professionals in 62 countries said they would use St. Johnís wort for mild to moderate depression. Although St. John's wort appears to be a safe alternative to conventional antidepressants, care should be taken, as the herb can interfere with the actions of some pharmaceuticals. The usual dose is 300 mg three times daily.

Orthomolecular therapy

Orthomolecular therapy refers to therapy that strives to achieve the optimal chemical environment for the brain. The theory behind this approach is that mental disease is caused by low concentrations of specific chemicals. Linus Pauling believed that mental disease was caused by low concentrations of the B vitamins, biotin, vitamin C , or folic acid . Supplementation with vitamins B₁, B₂, and B₆ improved the symptoms of depression in geriatric patients taking tricyclic antidepressants. The amino acids tryptophan, tyrosine, and phenylalanine have been shown to have positive effects on depression, although large, controlled studies need to be carried out to confirm these findings.

S-ADENOSYL-METHIONINE. In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. The usual dosage is 200 mg to 400 mg twice daily. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without

the side effects of stomach upset and decreased sexual desire.

5-HYDROXYTRYPTOPHAN. 5-hydroxytryptophan (5-HT, 5-HTP ) is a precursor to serotonin. Most of the commercially available 5-HT is extracted from the plant Griffonia simplicifolia. In several small studies, treatment with 5-HT significantly improved depression in more than half of the patients. One review of these studies suggests that 5-HT has antidepressant properties, however, large studies must be performed to confirm this finding. The usual dose is 50 mg three times daily. Side effects include nausea and gastrointestinal disturbances.

Homeopathic remedies

Homeopathic remedies can be helpful treatments for depression. A homeopathic practitioner should be consulted for dosages, but common remedies are:

• Arum metallicum for severe depression
• Ignatia for adjustment disorder
• Natrum muriaticum for depression of long duration.

Light therapy

Light therapy is helpful in controlling the depression of seasonal affective disorder (SAD). Treatment consists of exposure to light of a high intensity and/or specific spectra for an hour per day from a light box placed on the floor or on a table. The light intensity is usually 10,000 lux which is similar to the light of a sunny day. The opposite may be used, as well, which is the use of a dawn simulator for those patients who have an overdose of light exposure and require more sleep with less light. Most persons will see an effect within three to four weeks. Side effects include headaches, eye-strain, irritability, and insomnia. A week or more in a sunny climate may improve SAD.

Allopathic treatment

Depression usually is treated with antidepressants and/or psychosocial therapy. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed patient.

Drugs

Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety, diarrhea , drowsiness, headache , sweating, nausea, poor sexual functioning, and insomnia all are possible side effects of SSRIs. A recent study shows this generation of drugs increases patients' risk of gastrointestinal bleeding.

Tricyclic antidepressants (TCAs) are less expensive than SSRIs, but have more severe side effects including persistent dry mouth , sedation, dizziness , and cardiac arrhythmias. Because of these side effects, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs can be lethal if ingested all at once, so these drugs may not be a preferred treatment option for patients at risk for suicide.

Monoamine oxidase inhibitors (MAO inhibitors), such as tranylcypromine (Parnate) and phenelzine (Nardil), block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must avoid foods high in tyramine (found in aged cheeses and meats) to avoid potentially serious hypertensive side effects.

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion is prescribed to patients with a seizure disorder. Side effects include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure, and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia. Other possible side effects of trazodone include dry mouth, gastrointestinal distress, dizziness, and headache. In 2003, Well-butrin's manufacturer released a once-daily version of the drug that offered low risk of sexual side effects or weight gain.

Electroconvulsive therapy

ECT, or electroconvulsive therapy, usually is employed after all therapy and pharmaceutical treatment options have been explored and exhausted. However, it is sometimes used early in treatment when severe depression is present and the patient refuses oral medication, or when the patient is becoming dehydrated, extremely suicidal, or psychotic.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss , typically transient, has also been reported in ECT patients. ECT causes severe memory problems for months or years in one out of every 200 patients treated.

Late in 2001, a study reported on a pacemaker-like device used to treat epilepsy adapted for patients with depression. An implanted electronic device sends intermittent signals to the vagus nerve, which in turn carries the signals to the brain, connecting in areas known to regulate mood. Although still experimental at this time, early results in treating depression have been encouraging.

Expected results

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80–90% of depressed patients. After each major depressive episode, the risk of recurrence climbs significantly—50% after one episode, 70% after two episodes, and 90% after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment.

Overall, recent recommendations from mental health clinicians suggest that the recovery process for patients with depression works best when mental health professionals focus on the whole person behind the disorder. In addition to prescribing medications, they also should address a patient's self-esteem, feeling of control, and determination. They emphasize that patients with depression need a sense of optimism and should be encouraged to seek the support of family members and friends.

Prevention

Patient education in the form of therapy or self-help groups is crucial for training patients with depressive disorders to recognize early symptoms of depression and to take an active part in their treatment program. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention with children with depression is effective in halting development of more severe problems.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Peightel, James A., Thomas L. Hardie, and David A. Baron. "Complementary/Alternative Therapies in the Treatment of Psychiatric Illnesses." In Complementary/Alternative Medicine: An Evidence Based Approach. John W. Spencer and Joseph J. Jacobs, eds. St. Louis: Mosby, 1999.

Thompson, Tracy. The Beast: A Reckoning with Depression. New York: G. P. Putnam, 1995.

Ying, Zhou Zhong and Jin Hui De. "Psychiatry and Neurology." In Clinical Manual of Chinese Herbal Medicine and Acupuncture. New York: Churchill Livingston, 1997.

PERIODICALS

"A Natural Mood-booster that Really Works: a Group of Noted Researchers Found that the Supplement SAMe Works as Well as Antidepressant Drugs." Natural Health (July 2003): 22.

"Antidepression 'Pacemaker' Demonstrates Long-Term Benefits." Medical Devices and Surgical Technology Week. (December 30, 2001): 34.

Deltito, Joseph, and Doris Beyer. "The Scientific, Quasi-scientific and Popular Literature on the Use of St. John's Wort in the Treatment of Depression." Journal of Affective Disorders 51 (1998): 345-351.

"FDA Approves Once-daily Supplement." Biotech Week (September 24, 2003): 6.

Head, Kathi. "Conquer Depression Without Drugs." Let's Live 68 (2000): 72+.

Jancin, Bruce. "Chronic Pain Affects 67% of Patients With Depression: 'Stunning' Finding in Primary Care Study." Internal Medicine News (September 15, 2003): 4.

Miller, Mark D. "Recognizing and Treating Depression in the Elderly." Medscape Mental Health 2, no.3 (1997). http://www.medscape.com.

Miller, Sue. "A Natural Mood Booster." Newsweek (May 5, 1997): 74-5.

"New Depression and Anxiety Treatment Goals Defined." Health and Medicine Week. (December 31, 2001): 24.

Salmans, Sandra. "More on Treatments." Depression: Questions You Have .. Answers You Need (1997): 145+.

Sansone, Randy A. and Lori A. Sansone. "Dysthymic Disorder: The Chronic Depression." American Family Physician 53, no. 8 (June 1996): 2588-96.

"St. John's Wort Healing Reputation Upheld?" Nutraceuticals International. (September 2003).

"Try Alternatives Before Using Antidepressants." GP. (September 29, 2003): 12.

ORGANIZATIONS

American Psychiatric Association (APA). Office of Public Affairs, 1400 K Street NW, Washington, DC 20005. (202) 682-6119. http://www.psych.org/.

American Psychological Association (APA). Office of Public Affairs, 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. http://www.apa.org/.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754. (800) 950-6264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. http://www.ndmda.org.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02, Bethesda, MD 20857. (301) 443-4513. http://www.nimh.nih.gov/.

Belinda Rowland

Teresa G. Odle

DEPRESSION.

The cyclical downturn in the U.S. economy that began in summer 1929 has overcome all rivals to the title Great Depression. It challenged and overturned the confidence of Americans at the end of a decade in which the United States had stamped its political and economic dominance on the world. The pictures of long lines of hopeless men with no job to look for, of crowds besieging banks with no money to pay out, serve as a potent reminder of the fallibility of economic institutions and of prosperity. They still serve as a prompter to the American conscience and as a permanent stimulus to explain why the Depression occurred. However, what made it so great a depression was that neither its causes nor its consequences were limited to the United States. It was a worldwide phenomenon whose length, depth, and violence revealed the extent of the United States' involvement in and dependence on the international economy.

ORIGINS OF THE DEPRESSION:
THE UNITED STATES

The conclusion that the Great Depression's origins lay in the United States is often drawn from the long decline in prices on the Wall Street stock exchange after September 1929. The decline accelerated violently in the panic selling of 24 and 29 October, still the two worst days in the history of the U.S. stock exchange, when twenty-eight million shares were sold. When the market temporarily stopped falling in November, however, its level was as high as it had been in mid-1928. Only about 8 percent of the population owned stocks, and they were the wealthy, so that any fall in national consumption from this event was small. Furthermore, the stock market financed only about 6 percent of gross private national investment. But longer periods of declining stock prices were still to come in 1931, and the downward trend continued into 1933.

So long a trend was evidently a deflationary force in the economy, but it was by no means the greatest such force. More influential for the whole economy were the declining prices for foodstuffs and other primary products. The falling incomes from farming in 1931 left farmers unable to pay their debts, provoking numerous bank failures. Repossessions from those failures drove the stock market down from April that year until shares in manufacturing were barely more than a quarter of their value in November 1929.

There is some evidence that the fall in the stock market was related to certain aspects of consumption in the 1920s, notably the purchase of automobiles, radio equipment, and housing, acquisitions that depended on credit. Sales of U.S. automobiles for export began to decline a year before the onset of the stock market crash, for domestic consumption as early as March 1929. Domestic purchases had fallen by one-third by September 1929. The housing market began to slow down in summer 1929. Nevertheless, the steepness of the general economic downturn in 1929 was not so exceptional, compared to other downturns, as to indicate the subsequent length and severity of the Depression. The Wall Street crash undoubtedly did reveal some of the risks of new methods of selling consumer goods as well as the inequalities of personal income distribution in the United States, but such factors were not sufficiently influential to account for the totality of what followed, although they played their part in the bank crashes. Consumer durables did not suffer the biggest falls in sales and output.

The Depression's severity is sometimes attributed to errors of monetary policy in the United States. The growth of money supply was deliberately reduced by the Federal Reserve Bank from 1928 to check stock market speculation. Supply fell by 33 percent between August 1929 and August 1933. Shortage of liquid funds is blamed for the many bank failures in 1931. Authorities, however, believed monetary policy to be too lax because interest rates were lower than in earlier cyclical downturns in the decade. It is difficult to see how an increase in the money supply to the American economy in late 1930 could have prevented the abandonment by other countries of the existing international trade and payments machinery, especially the United Kingdom's departure from it in September 1931, when it gave up the gold standard. The outstanding characteristic of the Great Depression was its international scope. Country after country was caught in a vortex of declining output, earnings, and employment, and this makes the contribution of monetary policy in the United States, while it may have been unwise, too small a factor to account for so cosmic an event.

Of the major industrial countries, the United States and Germany were the hardest hit. Even in those more lightly hit—Sweden and the United Kingdom, for example—the decline in industrial production was severe. Beyond industrialized America and western Europe, however, foodstuff and raw material suppliers, such as Argentina, Brazil, Australia, and New Zealand, suffered declines in agricultural output, with severe drops in gross domestic product. The relentless devaluation of bond earnings was matched by a relentless and more widespread fall in agricultural profits. In other aspects too the American deflation marched in step with a worldwide deflation.

ORIGINS OF THE DEPRESSION IN GERMANY

The First World War established financial links between the United States and Germany that go some way to explaining the similarity of their experiences from autumn 1929 onward. There are those who see the origins of the Great Depression in these links or, indeed, in Germany itself. The postwar adjustment to a world in which the First World War had promoted the protection of new industrial developments made life more difficult for Europe's two major industrial producers, Germany and Britain. Those difficulties were reflected in their balance of payments problems after 1918, but for Germany these were exacerbated by the imposition of so-called reparations to be paid to the victors. The American insistence on the repayment by its allies in the war of all loans to them from the United States added an extra burden on the international payments system. It encouraged, moreover, the biggest borrowers, France and the United Kingdom, to demand reparations payments from Germany in full in order to repay their American loans. The weight of these transfers on the German economy, the temptation not to resist inflation of the currency too strenuously, when it might make reparations a lighter burden or even persuade the Allies that it was an impractical solution, played their part in the spectacular collapse of the exchange value of the German mark. Its value against the dollar fell from 103.65 in January 1920 to 414,000 at the end of July 1923 and to 3,300,000 in August 1923. The social disorder that long adherence to the gold standard had averted triumphed in defeat, occupation, and hyperinflation, soon to be followed by the political disorder of the National Socialist Party.

The actual sum required in reparations after the hyperinflation was between 50 and 125 million pounds sterling annually. To pay such a sum in manufactured exports to the protectionist United States was not seriously contemplated in Washington. Insofar as it was paid, it was so from the stream of dollar capital imports into Germany for postwar reconstruction. New capital issues, specifically for Germany, guaranteed or controlled by the U.S. government amounted to $176.3 million in 1928. Corporate issues without government guarantee or control amounted to $10.1 million. In 1930 government guaranteed issues amounted to $143.3 million; non-guaranteed issues to $23.5 million (figures from Secretariat of the League of Nations, pp. 320–321.) These transfers were established on a flexible basis in 1924 by the Dawes Plan, which through its transfer committee tailored the sums annually to what seemed feasible. The Dawes Plan constituted an official framework for American capital exports to Germany. With this seeming extra security, capital imports into Germany amounted to about 3 billion marks per year over the period 1924–1927. In that period the peak year for reparations payments amounted to almost 1.6 billion marks in 1927.

The inflow of American capital began to shrink in 1928 after an increase in American interest rates and a deepening unease about economic conditions in Germany. Opinion remains divided about whether the downturn in the German economy in 1929 was domestic in origin, resulting from a decline in investment, or external, from the recall of American capital investment due to, or perhaps earlier than, the onset in 1929 of the Wall Street crash. The evidence points more to international origins. In either case, the German response was to cut back on commodity imports, wages, and public expenditure. The government of Heinrich Brüning could see no way forward to meet the cost of imports plus reparation payments other than through cuts deep enough to preserve a balance of payments surplus, which was in fact achieved in 1932. By that date the world's two biggest manufacturing producers and exporters, the United States and Germany, were locked together in spiraling deflation, falls in industrial output, and steeply declining national product. A devaluation of the mark to stimulate German exports would have made the dollar value reparations more expensive to meet.

The Young Plan of 1929–1930, in a last attempt to preserve international cooperation in the payment of reparations, further reduced the German government's room for maneuver. Under the Dawes Plan the transfer of payments had been allowed only if the German balance of payments was not endangered. The Young Plan imposed a binding scheme for repayment spread over a longer period but removed in doing so the safeguard against transfers when the German balance of payments was threatened. In theory, this should have deterred foreign lenders, but while net capital imports fell, total capital imports were still high in 1930 and 1931. The lack of any obvious explanation of this trend only strengthened the German government's commitment to a balanced budget, achievable only by a deflationary policy, worsening the international crisis. This policy did produce substantial export surpluses for paying reparations to a similarly deflationist United States.

THE NECESSITY AND THE FAILURE
OF INTERNATIONALISM

In retrospect the Dawes Plan appears as the one instance of an internationalized solution that offered a way forward to the United States, to Germany, and thus, if the framework could have been extended, to America's other European debtors. After the events of 1929 it was perhaps too late. Perhaps, also, genuine internationalism could not have been born from so violent an event as the Franco-Belgian invasion and occupation of the Ruhr and the Rhineland in January 1923, intended to compel Germany to pay the reparations. The devaluation of the German mark was one consequence, well illustrating the fundamental reality that effective international trade and payments machinery depends absolutely on international political cooperation. It was lacking.

For ten countries to be recompensed by operations from Germany, for the United States to be repaid by its wartime allies, the prewar machinery for international trade settlements—the gold standard—would be put under heavy strain because of the economic and political boundary changes resulting from the First World War. Evidently, if war debts and reparations were to be repaid, Germany had to remain a prosperous and stable society, if only because it was one of the world's three major trading powers. Instead, it was riven by recriminations, denunciation of reparations, bitter internecine political struggle, and, by 1931, the climb to power of the National Socialist Party, threatening to end the democratic constitution and to overturn the Treaty of Versailles. Yet about three-quarters of the borrowing by German credit institutions and by local governments was from the United States, and the flow continued even in 1931.

America's wartime allies could not congratulate themselves on having restored by their own political decisions a durable framework of politico-economic cooperation. Faced with the fragmentation of the Habsburg Empire into its ethnic component parts, with the replacement of the Russian Empire by the Soviet Federation and then the Soviet Union, governed by self-proclaimed international revolutionaries, western European states were mainly concerned to preserve their prewar socioeconomic governing practices. In particular this meant continuing to depend mainly on established import and excise taxes for revenue so that the balance of the fiscal burden did not fall proportionately more heavily on the middle class than it had before the war, a political stance that strengthened their commitment to obtaining reparations from Germany in lieu of tax reform at home. The same conservative longing for the prewar world led in the direction of reestablishing a settlements mechanism for international trade as close as possible to the prewar gold standard, by which the price of gold was kept within narrow limits and either gold or foreign currencies convertible into gold within these limits were kept as central bank reserves and used to settle international debts.

The important question was at what rate the exchange between gold and national currency would be reestablished. Most countries, taking account of the changes in trade patterns caused by the creation of new countries out of the Habsburg Empire, expected initial difficulties in returning to the prewar system and selected lower exchange rates against gold and the dollar than the prewar rate. New countries also aimed at a low rate. The United Kingdom did not. In its own conservative gesture toward its major role in the prewar trade and payments system, it returned to the prewar pound/dollar exchange rate, increasing the price of its exports against those of European competitors.

There was no effort to coordinate internationally the rates of exchange that countries chose. While the new British rate forced deflation on the United Kingdom, France experienced a persistent inflation and currency depreciation until 1926, when the franc was "stabilized" with the backing of legislation shaped to prevent further inflation. This disorderly return to a form of gold standard among the world's major traders became a barrier to their attempts to escape from the worldwide deflation of 1929. It did more to sustain the Depression or, through trade competition, enforce it on others. While the French economy grew vigorously with inflation until 1926–1927, French foreign investment in the United States and the United Kingdom was high. The 1926 stabilization of the franc pushed the United States and the United Kingdom into further difficulties as gold flowed back into France, but the Bank of France was unable, because of the 1926 legislation, to readjust its exchange rate for fear of stimulating inflation.

The variety of national experiences in the timing and depth of the Great Depression reflects the haphazard return to separate national visions of the past and future. A significant element in British post-1918 trade deficits was the decline in Britain's prewar staple exports, already declining after 1890: textiles, cotton thread, ships, coal, and pig iron. In 1928 British shipbuilding was utilizing only about half of its total capacity, cotton about three-quarters. Most of the activity in such industries being regional, the pattern of unemployment was much more regional than, for example, in the United States or Germany. The regions officially characterized as "old industrial"—the north of England, southern Wales, and central Scotland—contributed 50 percent of net national industrial output in 1924, but only 38 percent in 1935. In the Midlands and southern England newer industries, especially automobiles and chemicals, contributed 29 percent of net industrial output in 1924 and 37 percent in 1935. In those newer industrial regions consumer goods sales grew and housing construction boomed, in contrast to the United States' experience. Nevertheless, on the national scale mass unemployment accounted for more than half the British people living in "primary poverty" in 1936, a measure of the slowness with which the United Kingdom adjusted to post-1918 trading conditions.

THE COLLAPSE OF THE GOLD STANDARD

In addition to the adjustment problems after the First World War and the tendency of the restored gold standard to impede recovery from the deflationary pressures that announced themselves in 1929 in the industrialized nations, the low level of prices of primary products was a further persistent source of deflationary pressure on the larger world economy. While the price of agricultural goods fluctuated markedly in the mid-1920s, the overall terms of trade between developed, industrialized states and states that produced mainly raw materials and food moved in favor of the industrialized states in the interwar period. As a market for manufactured exports, the world's primary product producers were weakening before and throughout the Great Depression. Forty percent of British exports, the great body of which were manufactured goods, were exported to primary producers while at the same time declining industries such as cotton thread and textiles were facing increasing competition from slowly industrializing primary producers such as India.

Many large primary producing counties were heavily dependent on a narrow range of products. Raw wool accounted for about 41 percent of Australian exports by value, cotton for about 80 percent of the value of Egyptian exports. From other primary producers foodstuffs dominated exports: 75 percent of Cuba's exports was sugar, 71 percent of Brazil's was coffee. It is not surprising that such primary producers were among the first to abandon the gold standard. Argentina, Brazil, Australia, and New Zealand all did so before 1930. The main markets for the industrialized countries were each other. The fall in their exports to primary producers was of too small a total value to weigh against the value of the interchange between developed economies, but the poverty of the agricultural producers was one more barrier to escaping from deflation.

The manufacturing economies held out longer on the gold standard. The collapse of the Credit Anstalt bank in Austria in 1931 led in July to the imposition of exchange and trade controls by Hungary. In the same month Germany also imposed exchange and trade controls. In September the United Kingdom abandoned a century of the pursuit of free trade when it left the gold standard and simultaneously devalued the pound sterling against the gold dollar by 30 percent while preparing a general tariff. The exchange rate of the pound, technically floating, was thence-forward determined by the Bank of England's management of the floating rate. As the 1930s turned increasingly toward war, quantitative trade controls, mainly import quotas, supplemented protectionism. In Germany and much of central Europe, annual bilateral trade agreements strictly controlled the goods traded and the value of their currency. The new German Reichsmark, for example, was not convertible. France and Germany became insignificant trading partners of each other. British trade, directed by tariff preferences and the retention of sterling as a convertible currency within the Commonwealth, increased with distant Australia and New Zealand and decreased with neighboring European industrial producers. None of these outcomes was conducive to recovery. Protection of domestic agriculture from foreign imports became general in Europe and the United States. It was to be well into the 1950s before these trade barriers began to be carefully and slowly reduced and the automatic convertibility of European currencies into gold/dollars began to be reinstated.

The search for national causes of the Great Depression, whether in the United States or Germany or elsewhere, seems a somewhat limited enterprise when so much evidence shows that the system of international settlements was so

defective, without central authority or agreed objectives, while being so effective at transmitting deflation to each and every one of the main trading nations. Consider but the case of the United Kingdom, whose central bank had played so facilitating a role in the pre-1914 gold standard. With large prewar surpluses on goods, turned by 1920–1924 into a small deficit, and with a deficit on long-term capital flows, it was in no position to return to the exchange rate against the dollar of the years when it had been seen as a manager of the system. There was no manager of the system in the interwar period.

To blame the United States, as some do, for not stepping into the role of "hegemon" is greatly to exaggerate the authority that a hegemon could have exerted in so divided a world. Hegemony would in any case have been no substitute for international agreement but only a prop to it. International agreement had to wait for a much greater sense of common purpose, such as came in the Cold War of the 1950s, furthered, no doubt, by the terrible consequences of the National Socialist government in Germany.

RECOVERY

If the first step toward recovery was to break the constraints of the gold standard, one would expect the countries that stayed on gold until the late 1930s to show a lower rate of recovery than those that left it. France, Belgium, and the Netherlands, three countries that stayed longer on gold, do show a lower level of recovery by 1937/38 than others. The spectacular recovery of Germany to full employment and high levels of output reflects the extent of concentration on rearmament, broadly defined. The two countries that had suffered the worst falls in output, Germany and the United States, showed the biggest gains, although in the United States this recovery was much less attributable to rearmament than in Germany. Yet by summer 1938 there were undeniable indications of another economic downturn. It would be no exaggeration to say that the threat of another world war led to a more convincing upturn in 1941 in the United States.

A more apt comparison is between France and Belgium on the one hand and the United Kingdom on the other. Breaking the shackles of the gold standard in the way that the United Kingdom did was a serious blow to international cooperation; Britain could be fairly accused of pursuing a beggar-my-neighbor policy. It is not, though, necessarily true that all countries that abandoned the gold standard were making things harder for those, like France, who remained on it, for they were relinquishing gold for those who sought, like France, to acquire it. Furthermore, the evidence from all countries, including those that left the gold standard, is that reflation was undertaken only cautiously. The theoretical demonstration by the British economist John Maynard Keynes that increased public expenditure was necessary for a return to economic equilibrium after so catastrophic a slump made more impact toward the end of the decade than at the start of the recovery. Concentration of expenditure on rearmament and public works, as in Germany, cut off the economy from its long-established trade relations with neighboring states that stayed on gold. German trade with France was insignificant by 1937. British trade and income recovered only slowly. Even after six months of war and military conscription and seven years of increasing rearmament expenditure, about a million working-age men in Britain were still registered as seeking work in early 1940. Only in Germany did public works expenditure, on express highways and on the stimulation of the automobile market, produce large increases in employment by 1935/36. Its objective, however, was not a return to equilibrium, at least not within Germany's existing frontiers. Germany imposed such draconian controls on the national currency as to make it unwanted beyond the national frontier. Fear of hyperinflation gnawed at the heart of all countries that had experienced it in the 1920s. In these circumstances the increase in money supply that freedom from the gold standard permitted helps to explain less than half the adjustment to higher capacity utilization of manufacturing plants in the major industrial countries by September 1939. The shadow of the Great Depression thus hovered over all who had been caught in its coils, whatever their subsequent governments or their actions in seeking recovery.

See alsoBretton Woods Agreement; Capitalism; Inflation.

BIBLIOGRAPHY

Aldcroft, Derek H. From Versailles to Wall Street, 1919–1929. London, 1977.

Eichengreen, Barry. The European Economy, 1914–1970. London, 1978.

——. Golden Fetters: The Gold Standard and the Great Depression, 1919–1939. New York, 1992.

Fearson, Peter. The Origins and Nature of the Great Slump 1929–1932. London, 1979.

Friedman, Milton, and Anna J. Schwartz. A Monetary History of the United States, 1867–1960. Princeton, N.J., 1963.

Mouré, Kenneth. The Gold Standard Illusion: France, the Bank of France, and the International Gold Standard, 1914–1939. Oxford, U.K., 2002.

Secretariat of the League of Nations. The Course and Phases of the World Economic Depression. Rev. ed. Geneva, 1931.

Sering, Max. Germany under the Dawes Plan: Origin, Legal Foundations, and Economic Effects of the Reparation Payments. Translated by S. Milton Hart. London, 1929.

Temin, Peter. Did Monetary Forces Cause the Great Depression? New York, 1976.

Alan S. Milward

Depression

Definition

Depression is the most common mental disorder. It is an illness that affects emotions, moods, thoughts, energy, behavior, and physical health and interferes with daily life.

Description

There are two major types of depression—major depressive disorder and dysthymia. Major depressive disorder is defined as five or more symptoms of depression lasting at least two weeks. It is also called:

• major depressive illness
• clinical depression
• major affective disorder
• unipolar mood disorder

Depressive episodes may recur monthly, annually, or several times during one's life. Dysthymia is a long-lasting or chronic depressed mood that is less severe than major depression but may be just as disabling.

Less common types of depression include:

• seasonal affective disorder, usually occurring in the winter months
• psychotic depression, severe depression that is complicated by psychosis or loss of contact with reality
• vascular depression, associated with blood vessel damage or “silent” strokes that cause lesions in the brain, particularly in the prefrontal cortex

Many older adults with depression had depressive episodes earlier in life. Others seniors experience their first depressive episode at age 80 or 90. A first episode of depression occurring late in life is usually brought on by another medical condition, a disability, or forced dependence on others.

The World Health Organization states that depression will be the second most common cause of death after heart disease by the year 2020. Unrecognized and untreated depression is a major problem among seniors. Older depressed patients often stop eating and/or sleeping and can easily become debilitated. Older adults have a far higher suicide rate than any other age group and depression is the most important risk factor for suicide among seniors. Suicide attempts are much more likely to be successful in seniors than in younger people. Depression in the elderly has become a very active area of research in many countries.

Demographics

Depression can affect anyone regardless of age, ethnicity, or socioeconomic class. At some point in their lives, 24% of all women and 15% of men experience depression. Depression most often first occurs between the ages of 25 and 44. Estimates of the prevalence of major depression in older people vary greatly, in part because older adults are much less likely to report symptoms of depression. Some epidemiological studies have indicated that older people are generally less depressed than younger people, whereas other studies have found that the incidence of depression is similar in the two groups. Major depression is estimated to affect 5–20% of Americans over age 65. The prevalence of major depression declines with age, but symptoms of depression—perhaps constituting dysthymia—increase with age, particularly among women. Dysthymia is thought to affect about 37% of older adults in hospitals an nursing homes .

Depression in seniors is sometimes mistaken as a normal sign of aging and is thus underreported. Seniors may be reluctant to seek help for depression because they do not understand mental disorders, they are ashamed of their symptoms or because Medicare offers very few benefits for psychiatric care. Depression can mimic dementia and some experts believe that as many as 10% of seniors diagnosed with dementia actually have reversible depression.

Unmarried older adults and those lacking a supportive social network are more susceptible to depression. Susceptibility to depression may be increased by:

• low self-esteem
• a family history of depression or suicide
• less than a high school education
• stressful life events such as death, divorce, relocation
• exposure to violence, abuse, or neglect
• poor economic situation
• alcohol or drug abuse
• giving birth

The prevalence of clinical depression in seniors is about 25% in those with chronic illness, especially:

• heart disease

• stroke

  Percentage of people in the United States age 65 and over with clinically relevant depressive symptoms, by age group and sex, 2004

  	Men	Women	Both sexes
  Clinically relevant depressive symptoms refers to four or more symptoms out of a list of eight depressive symptoms from an abbreviated version of the Center of Epidemiological Studies Depression Scale (CES-D) adapted by the Health and Retirement Study (HRS).
  source: Adapted from Health and Retirement Study, Institute of Social Research, University of Michigan
  (Illustration by GGS Information Services. Cengage Learning, Gale)
  65–74	9.7%	15.6%	13.1%
  75–84	10.6%	17.7%	14.8%
  85 and over	19.2%	19.2%	19.2%

• cancer
• lung disease
• arthritis
• Alzheimer's disease
• Parkinson's disease
• HIV/AIDS

Among people with diabetes, 10–15% have had at least one major depressive episode.

Other medical conditions associated with depression in seniors include:

• surgery
• trauma such as an automobile accident
• hip fractures
• macular degeneration
• hyperthyroidism
• dementia or other nervous system and brain disorders

Causes and symptoms

Biological causes

Although the exact cause of depression is unknown, imbalances or low activity of brain chemicals called neurotransmitters (such as serotonin and norepinephrine) are known to play a role. Levels of all neurotransmitters decline with age. People in their 80s have serotonin levels that are half of what they had in their 60s, although it is not clear whether this is associated with increased depression.

Depression may have a genetic component since the disorder can run in families. A first onset of depression after age 60 is less likely to be associated with a genetic predisposition.

Hypothyroidism, caused by deficient thyroid gland activity, is a common disorder that causes depression. Other conditions that can cause depression include:

• vitamin deficiency
• potassium deficiency
• a brain tumor
• stroke on the left side of the brain
• cancer

Medications that can cause depression include:

• corticosteroids
• some antihypertensives for treating high blood pressure, such as methyldopa and reserpine
• digoxin for treating heart disease
• opiod analgesics

The vascular hypothesis of late-onset depression suggests that disorders causing vascular damage—such as high blood pressure , coronary artery disease, and diabetes—induce brain changes that result in susceptibility to depression.

Changes in brain chemistry that may contribute to depression can be triggered by:

• hormonal changes, particularly in older women
• substance abuse
• cancer or other illness
• a traumatic event

Experiential causes

Persistent insomnia , which occurs in 5–10% of older adults, is a risk factor for late-onset depression. At least 10–20% of widows and widowers develop clinical depression within the first year of their spouse's death. Other factors that can trigger or contribute to depression in seniors include:

• life experience
• retirement
• a changing neighborhood
• moving to a new situation
• loss of friends or loved ones
• feelings of worthlessness or isolation
• loss of mobility
• anxiety over loss of control or inability to deal with daily tasks
• loss of independence
• worsening of a chronic disease
• changes in hearing or vision

Symptoms

Symptoms of depression in seniors may differ from those in younger people and may include:

• sadness lasting at least two weeks
• a feeling of emptiness
• apathy, emotional bluntness, or overreaction
• excessive worrying about finances or health
• restlessness, poor concentration
• memory problems
• social withdrawal
• fatigue
• weight gain or loss of appetite
• constipation
• irritability
• paranoia, delusions, or hallucinations
• dizziness
• confusion
• thoughts of death or suicide

Insomnia and sleep disturbances are particularly common in older depressed adults.

Instead of recognizing their depression seniors often complain of physical problems including backaches, joint pain , headaches , or stomach problems.

Symptoms of major depression include:

• unexplained crying spells
• low self-esteem, feelings of inadequacy, lack of self-confidence
• guilt, brooding about the past
• anger, anxiety, agitation
• pessimism, hopelessness, despair
• lethargy
• indecisiveness
• excessive alcohol or drug use

Symptoms may be worse at certain times of day, especially in the morning. Some older people who are depressed stop performing daily activities or caring for themselves.

Late-onset depression (a first episode after age 60) can be distinguished by greater apathy, less lifetime personality dysfunction, and increased cognitive deficits.

Vascular depression shares symptoms with other forms of depression but has some distinctive features:

• Anhedonia, the inability to look forward to pleasurable events, is common.
• Patients are less likely to have a family history of mood disorders.
• Patients are less likely to have a history of substance abuse or previous depression.
• Patients are generally more impaired.

Diagnosis

Many experts advocate using a series of questions during regular physical exams to screen seniors for depression. Depression is more difficult to diagnose and assess in seniors for the following reasons:

• Older people may be reluctant to talk about their symptoms.
• The elderly may have fewer social interactions.
• Family and friends may attribute symptoms to normal aging.
• Common medical conditions, such as Parkinson's disease, heart disease, or dementia, may mask symptoms of concurrent depression.
• People with dementia or stroke may be unable to express their feelings of depression.

One criterion for distinguishing depression from dementia is that older people who are depressed are confused and bothered by their forgetfulness, whereas those with dementia may deny any forgetfulness.

A diagnosis of depression should include a family history and complete physical examination to rule out other medical conditions that may be causing symptoms. Depression can be distinguished from sadness and grief at the loss of a home or loved one or other traumatic event if symptoms persist for more than two months or are accompanied by:

• guilt unconnected with the death of a loved one
• feelings of worthlessness
• insomnia
• weight loss
• inability to function normally
• thoughts of dying

Since dysthymia is not necessarily debilitating, seniors may be unaware that they are ill. Dysthemia is diagnosed when symptoms last more than two years without a break of more than two months.

Treatment

Although alleviating pain and nausea, getting support from family and friends, peer-support groups, self-help, proper care, and relaxation techniques may relieve symptoms of mild depression, mild to moderate depression is usually treated with either medication or psychotherapy. Severe depression usually requires both. Treatment for major depression is especially important for seniors because of the higher risk of depression-associated suicide. Geriatric psychiatrists specialize in treating late-life depression.

Antidepressants

The antidepressants prescribed for seniors are similar to those prescribed for younger patients but their selection is more complex because of side effects and interactions with other medications. Side effects that may be annoying in younger patients can lead to severe problems in the elderly. Normal aging and menopause can affect brain chemistry and may require a change in dosage or type of medication. Antidepressants can be highly effective in people nearing the end of life.

Selective serotonin reuptake inhibitors (SSRIs) are a commonly prescribed antidepressant. These medications have side effects, contraindications, and interactions with other medications. SSRIs selectively increase the level of serotonin available to the brain and central nervous system by blocking its reuptake. Citalopram and escitalopram are least likely to cause side effects and may relieve symptoms faster than other antidepressants. Fluoxetine and paroxetine are more likely to interact with other medications.

Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine; bupropion, which increases dopamine; and trazodone, which affects serotonin; have side effects that may be better tolerated by older patients. Older antidepressants such as tricyclics and monoamine oxidase inhibitors (MAOIs) affect numerous neurotransmitters, brain cell receptors, and brain processes, increasing the likelihood of serious side effects. MAOIs can also have dangerous interactions with certain foods and medications. These drugs are rarely used in older people.

It is often necessary to try different antidepressants or combinations of medications and they may have to be specially adjusted for seniors who are being treated for other illnesses. An SSRI that is effective after three weeks in a middle-aged adult may take 12 weeks or more to be effective in an elderly patient. Therefore, an antipsychotic medication is sometimes prescribed until the antidepressant takes effect.

Since depression is more likely to lead to malnourishment in seniors, psychostimulants such as methylphenidate, which can be effective within days and which stimulates appetite, may be prescribed for seniors who are not eating. Psychostimulants are also used for rapid relief in dying patients.

Seniors experiencing their first episode of depression are usually advised to continue the medication for 6–12 months after symptoms improve. Those with previous depressive episodes are advised to continue treatment for up to two years. Seniors with three or more previous depressive episodes may continue on medication for the remainder of their lives.

Psychotherapy

Psychotherapy has been shown to be particularly useful for older adults who cannot or will not take antidepressants. Sessions may be individual, include family members, or occur in a group of people with similar disorders. The goals of psychotherapy can include:

• separating personality from mood swings
• identifying triggers that worsen symptoms
• improving personal relationships
• establishing a stable routine
• addressing sleeping or eating irregularities
• overcoming fears and insecurities
• understanding previous traumatic experiences
• coping with anger, anxiety, irritations, and stress
• developing a plan for coping with crises
• ending destructive behaviors such as alcohol or drug use

Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been shown to be effective for treating late-life depression. They are usually short-term, lasting 10–20 weeks. CBT attempts to replace negative thinking and behaviors that contribute to depression with positive thoughts and behaviors. IPT focuses on improving personal relationships and on grief and role transitions. Problem-solving therapy and brief psychodynamic psychotherapy, lasting three to four months, have also been shown to be effective for treating late-life depression. Reminiscence therapy involves reflecting on positive and negative past life experiences to help overcome feelings of depression and despair. This therapy was developed specifically for older adults.

Other treatments

The use of electroconvulsive therapy (ECT) to treat severe depression in seniors is increasing, particularly for those who are unable to take antidepressants or for whom psychotherapy and medications are ineffective or too slow to relieve psychosis or suicidal thoughts. The rapid response to ECT can be crucial for a severely depressed patient who is not eating, drinking, or sleeping. A small electrical current is applied to the brain in a hospital under general anesthesia . The seizures caused by ECT may help relieve depression by causing the release of neurotransmitters.

S-adenosyl-L-methionine (SAM-e), an essential substance that regulates serotonin and dopamine levels in the brain, has been widely used in Europe to treat depression. Some studies have shown SAM-e to be as effective as antidepressants or to increase their effectiveness when used in combination.

Phototherapy is sometimes used to treat seasonal affective disorder. This type of therapy has patients sit in a room with a special light box or spend time outdoors.

Nutrition/Dietetic concerns

Healthy eating is important for managing depression. Depressed seniors should:

• eat plenty of raw fruits and vegetables and whole grains
• moderate intake of fat, cholesterol, sugars, and salt
• drink at least eight glasses of water per day
• limit or avoid caffeine and alcohol
• not skip meals
• avoid radical diets
• be aware of changes in appetite that could be signs of depression

Prognosis

Depression in seniors tends to be more chronic than in younger adults with recurrences lasting longer and remissions shorter. The risk of recurrence is particularly high in patients with late-onset depression. Fortunately, depression is one of the most treatable of all mental disorders and response rates to treatment are similar in older and younger adults. Response to treatment is slower and more variable in older patients though. About 80% of older adults with depression respond positively to medication, psychotherapy, or a combination, and ongoing treatment is very effective in reducing recurrences. Patients in psychotherapy often see significant improvement after 10–15 sessions. ECT is 50–70% effective in older patients. Even those who do not respond well to treatment usually experience some improvement in their ability to function and perform daily activities. Vascular depression is generally more difficult to treat but often responds as well.

QUESTIONS TO ASK YOUR DOCTOR

• How will my other medical conditions affect my treatment for depression?
• Is there a generic form of the prescribed medication?
• When should I take the medication? Should I take it with food?
• Are there any foods, medications, supplements, or activities that should be avoided while taking this medication?
• What if I miss a dose?
• What are the possible side effects of this medication and what can be done about them?
• How long before the medication takes effect and what type of improvement should I expect?
• Can I choose to stop taking this medication?
• Are there alternative treatments?
• Are there other things such as diet, physical activity, or lifestyle changes that may help with my depression?
• What type of psychotherapy might help?
• Are there support groups available that might be helpful?

Predictors of recurrence and relapse for late-life depression include:

• a history of frequent episodes
• severe pretreatment depression and anxiety
• first episode after age 60
• a concurrent illness
• infarction or vascular disease
• cognitive impairment, especially frontal-lobe dysfunction

Untreated, depression can affect the immune-system , leaving seniors susceptible to other illnesses. Studies have shown that chronic depression in older adults can increase the risk of certain cancers by 10–25%. Some research suggests that tumors grow faster in depressed people and depression at the time of cancer diagnosis is a predictor of a poor outcome. Depression also increases the risk of developing heart disease, osteoporosis , obesity , adult-onset diabetes, and chronic pain. The prognosis for hip fractures is worse in depressed seniors. Depression can also exacerbate substance abuse, eating and anxiety disorders.

Prevention

Several factors can help prevent episodes of depression:

• physical and mental activity
• social support systems
• regular sleep
• healthy eating
• avoidance of drugs, alcohol, and risky behaviors
• recognizing triggers and early warning signs

Aerobic exercise , in addition to improving immune and cognitive functions, increases the body's production of endorphins, which both prevents and treats depression.

Lifestyle changes that can help manage depression include:

• reducing stress and learning healthy coping strategies
• recognizing and managing the causes of stress
• communicating feelings through talking, writing, or other creative outlets
• relaxation methods including walking or light exercise, music, yoga, or meditation

Caregiver concerns

Caregivers often overlook symptoms of depression, mistaking them for normal aspects of aging. Some indicators of depression in the elderly are persistent and vague complaints, frequent phone calls, and a demanding behavior.

KEY TERMS

Cognitive behavioral therapy (CBT) —Psychotherapy for depression that attempts to replace negative thought patterns with positive ones.

Dopamine —A neurotransmitter in the brain.

Dysthymia —A milder chronic depression.

Electroconvulsive therapy (ECT) —A treatment for depression in which an electric current is applied to the head of an anesthetized person to induce seizures.

Endorphins —Brain peptides that bind to opiate receptors to produce pain relief and feelings of pleasure.

Hypothyroidism —Deficient activity of the thyroid gland that lowers the metabolic rate and causes fatigue and depression.

Interpersonal therapy (IPT) —Psychotherapy for treating depression that focuses on interpersonal relationships.

Major depressive disorder —Five or more symptoms of depression lasting at least two weeks and interfering with daily life.

Neurotransmitter —A substance that helps transmit impulses between nerve cells.

Norepinephrine —A neurotransmitter.

Psychostimulant —A fast-acting antidepressant.

S-adenosyl-L-methionine (SAM-e) —A substance in the body that regulates serotonin and dopamine levels and is used as an antidepressant in Europe.

Seasonal affective disorder —Depression that tends to recur with the shorter days of fall and winter.

Selective serotonin reuptake inhibitor (SSRI) —An antidepressant that increases serotonin in the brain.

Serotonin —A neurotransmitter in the brain.

Serotonin and norepinephrine reuptake inhibitor (SNRI) —An antidepressant that increases serotonin and norepinephrine in the brain.

Vascular depression —Depression associated with blood vessel damage or brain lesions.

Talk of suicide by older adults should always be taken seriously. It is appropriate to ask depressed people whether they:

• feel that life is no longer an option
• have thoughts of harming themselves
• are planning to harm themselves
• are often alone
• have pills or guns in their home

Seniors may need help remembering to take medications. It is estimated that 70% of seniors fail to take 25–50% of their prescribed medications. Medications should be taken at the appropriate times and side effects recorded. Caregivers should watch for possible drug interactions and indications that medications are affecting moods. Antidepressants should never be stopped without a physician's instructions for gradual withdrawal.

Resources

books

Chew-Graham, Carolyn A. Integrated Management of Depression in the Elderly. Cambridge, UK: Cambridge University Press, 2008.

Hart, Archibald D. Help! Someone I Love Is Depressed. Carol Stream, IL: Tyndale House, 2006.

Kramer, Peter D. Against Depression. New York: Viking, 2005.

periodicals

Bower, Bruce. “Depression Defense.” Science News 172 (August 18, 2007): 101–2.

“Depression; Home Care Program Seeks to Identify Depression in Senior Citizens.” Science Letter February 21, 2006: 418.

Wang, Shirley S. “The Graying of Shock Therapy.” Wall Street Journal December 4, 2007: D1.

other

American Psychiatric Society. “Let's Talk Facts About Depression.” November 2006 [cited April 6, 2008]. http://www.healthyminds.org/factsheets/LTF-Depression.pdf.

“Depression in Late Life: Not a Natural Part of Aging.” Geriatric Mental Health Foundation [cited April 6, 2008]. http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html.

“Depression in Older Adults.” Mental Health: A Report of the Surgeon General [cited April 6, 2008]. http://mentalhealth.samhsa.gov/features/surgeongeneralreport/chapter5/sec3.asp.

“Depression in Older Persons.” May 2003 [cited April 6, 2008]. National Alliance on Mental Illness. http://www.nami.org/Content/ContentGroups/Helpline1/Depres-sion_In_Older_Persons.htm.

Duckworth, Ken. “Understanding Major Depression and Recovery: What You Need to Know About this Mental Illness.” National Alliance on Mental Illness [cited April 6, 2008]. http://www.nami.org/Content/Content-Groups/Helpline1/NAMI_Major_Depression.pdf.

“Mental Health, Mental Illness, Healthy Aging: A NH Guide for Older Adults and Caregivers.” [cited April 6, 2008]. National Alliance on Mental Illness-New Hampshire. http://www.nami.org/Content/ContentGroups/Home4/Home_Page_Spotlights/Spotlight_1/Guidebook.pdf.

organizations

American Association for Geriatric Psychiatry, 7910 Woodmont Avenue, Suite 1050, Bethesda, Md, 20814, (301) 654-7850, http://www.aagponline.org.

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, (888) 35-PSYCH, [email protected], http://www.healthyminds.org.

Depression and Bipolar Support Alliance, 730 N. Franklin Street, Suite 501, Chicago, IL, 60610-7224, (800) 826-3632, (312) 642-7243, [email protected], http://www.ndmda.org.

National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA, 22201-3042, (703) 524-7600, (888) 950-NAMI, (703) 524-9094, http://www.nami.org/.

National Mental Health Information Center, P.O. Box 42557, Washington, DC, 20015, (800) 789-2647, (240) 221-4295, http://mentalhealth.samhsa.gov.

Margaret Alic Ph.D.

Depression

More Than Ordinary Sadness

Who Gets Depressed?

How Do People Know If They Are Depressed?

What Causes Depression?

Types of Depressive Illnesses

How Is Depression Treated?

Experiencing Depression

Resources

Organizations

Depression (de-PRESH-un) is a condition that causes people to feel long-lasting sadness and to lose interest in activities that normally give them pleasure. People with depression have continuing negative and pessimistic thoughts. They may experience changes in eating and sleeping patterns and in their ability to concentrate and make decisions.

KEYWORDS

for searching the Internet and other reference sources

Bipolar disorder

Dysthymia

Major depression

Mood disorders

Seasonal affective disorder

More Than Ordinary Sadness

Everyone feels sad occasionally, especially after a loss or a setback. Feeling down for short periods is perfectly normal. However, when sadness lasts several weeks and starts to interfere with normal activities, such as studying, relationships with friends and family, attendance at school, or activities that are normally fun, then it is more than an ordinary variation in mood. It is depression.

Depression is sometimes called an invisible disease, because it does not produce a rash or a fever or any other easily recognizable sign of a problem. In addition, many people are afraid or embarrassed to talk about how unhappy or hopeless they feel, mistakenly believing the feelings are a sign of weakness or a character flaw on their part. Sometimes those close to a person experiencing depression add to this mistaken belief by encouraging the person to simply “cheer up.” Because it often goes unrecognized, depression often goes untreated, but it is just as important to treat depression as it is to treat illnesses like diabetes or asthma. Depression should be treated by a mental health professional. The good news is that 80 to 90 percent of people with depression can be helped by treatment, often within a few weeks. Left untreated, however, depression can get worse and last longer. This needlessly reduces a person’s full participation in life. In severe cases, it can lead to suicide.

Who Gets Depressed?

Depression is a common illness that appears in several different forms. Up to 1 out of every 12 teenagers suffers from depression. In addition, about 1 out of every 10 adults experiences a period of depression in any given year. About one-fourth of all women and one-eighth of all men will experience at least one episode of depression during their lifetime.

Depression can be found in children, in elderly people, and in people of all ages in between. It affects people of all races, cultures, professions, and income levels. Women, however, experience depression about twice as often as men. The economic costs of depression in the United States, including lost wages, lost productivity, and treatment, are between $30 billion and $44 billion every year.

How Do People Know If They Are Depressed?

Depression differs from ordinary sadness or grief. With depression there is:

• a persistent feeling of sadness or emptiness that occurs daily and lasts longer than 2 weeks
• unhappiness or a feeling of worthlessness or guilt that interferes with normal activities
• loss of pleasure in activities that once were enjoyable, such as taking part in hobbies, listening to music, or going out with friends.

Not everyone experiences depression in the same way, but in addition to the symptoms listed above, other common changes that can occur include:

• eating too much or too little
• sleeping too much or too little; difficulty getting up or going to sleep
• unexplained periods or restlessness, irritability, or crying
• fatigue and decreased energy, even when getting enough sleep
• difficulty concentrating or remembering things
• difficulty making decisions
• increased interest in death
• thoughts of suicide

In his autobiographical book Darkness Visible, William Styron explores the possible sources of his debilitating depression, his recovery, and the history of this illness which has affected many other artists and writers. ©Liaison/Newsmakers/OnlineUSA

Preteens and teenagers experience many of these symptoms, but there are additional symptoms of depression that are common in young people. These include:

• ongoing physical problems, such as headaches, digestive problems, or persistent aches and pains that have no obvious physical explanation and do not respond to medical treatment
• increased absences from school or worsening school performance
• talking about or acting on the desire to run away from home
• unexplained outbursts of shouting, complaining, or crying
• increased irritability, anger, or hostility
• extreme sensitivity to failure or rejection
• being bored
• lack of interest in friends and a desire to isolate oneself
• increased difficulties in relationships with family, friends, or teachers
• alcohol or substance abuse
• reckless behavior
• abnormal fear of death

Because depression can involve physical symptoms, people with depression often consult their physician. This is very helpful since symptoms of depression can be symptoms of medical conditions as well. A medical check-up can determine if there is some medical reason for their symptoms, such as another disease or a side effect of medication. If these reasons are ruled out, a likely cause is depression. The physician may ask about feelings of sadness, hopelessness, or discouragement, loss of pleasure, and sleeping and eating problems to confirm a diagnosis of depression. The physicians then can discuss treatment options with the person, which may include a referral to a mental health professional for psychotherapy and, in some cases, medication.

What Causes Depression?

Experts are not exactly sure what causes depression. Depression is complex, but it appears to have mental, physical, genetic, and environmental components. These parts come together in different ways, making it difficult to pinpoint the exact cause of depression or predict who will become depressed and under what circumstances. One thing that is certain is that depression is not a weakness or a character flaw. It is not laziness or intentional bad behavior. People with depression cannot simply pull themselves together and drive out their sad and empty feelings, no matter how much the people around them encourage them to “snap out of it.”

Mental components

Depression affects a person’s thoughts, but it also seems that a person’s thoughts can affect depression. Why this happens is not clear. Some experts believe that depression comes from anger that is not expressed, but is directed inward at oneself instead. Others believe that negative thoughts feed depression, and that people who think negative things about themselves, the world around them, and the future encourage and deepen the depression. Feelings of being helpless and of having no choices, even if in reality choices exist, also can be mental components of depression. People who have low self-esteem and perfectionists who set unrealistic goals for themselves also are prone to depression.

Physical components

Researchers have found a link between depression and an imbalance of certain chemicals in the brain, called neurotransmitters*. Brain imaging techniques show that areas of the brain responsible for moods, thinking, sleep, appetite, and behavior function differently in some people with depression. In addition to differences in brain chemistry, some medical illnesses, such as stroke*, heart attack, cancer, or diseases that cause long-lasting pain, can sometimes trigger depression. In women, hormonal changes that occur just after the birth of a child cause some new mothers to experience postpartum (post-PAHRtum) depression, also called the “baby blues.” For most women, this is a mild, short-lived problem that goes away on its own after a week or so. In a few cases, though, the problem is more severe and long-lasting, and treatment is required.

* neurotransmitter

(NUR-o-transmit-er) is a chemical produced in and released by a nerve cell that helps transmit a nerve im-pulse or message to another cell.

* stroke

is a disorder in which an area of the brain is damaged due to sudden interruption of its blood supply. This is often caused by a blood clot blocking a blood vessel supplying the brain.

Genetic components

It appears that genetic (inherited) factors also cause vulnerability to some kinds of depression. This is demonstrated by the way that depression tends to run in families, and by twin research. Studies of twins have found that identical twins (twins who have the same genes*) are twice as likely to both experience major depression as are fraternal twins (twins who do not share all the same genes). Although a person with a parent, brother, or sister who has a depressive illness is more likely to become depressed than someone with no such family history, many people who have relatives with depression are not themselves depressed. For other people, depression seems to “come out of nowhere,” with no family history of the condition. This indicates that while genetic factors certainly contribute to depression, other factors play a significant role in whether the depression actually develops.

* gene

is a chemical found in the chromosomes in the body’s cells that passes on information, such as eye color, height, or other characteristics, from parent to child.

Environmental components

The death of a loved one, a failure at school or on the job, the end of a romantic relationship, or many other kinds of losses can trigger an episode of depression in some people. Depression is different from the normal mourning process that follows a loss. A person in mourning goes through distinct stages of psychological reaction to the loss, ending with the ability to accept the loss and resume normal functioning. With depression, the sadness continues over a long time with no progress being made toward acceptance of the change. There is no way to predict which environmental stresses will trigger depression in specific individuals.

Types of Depressive Illnesses

Depression can take a variety of forms. It may be mild, moderate, or severe. It may be mixed with periods of normal feelings or periods of abnormally heightened energy called manic (MAN-ik) periods, or depression may be continuous but low level. Some depressions occur seasonally. Although feelings of sadness, unworthiness, discouragement, and loss of interest in normally pleasant activities are common to all forms of depression, different depressive illnesses have different patterns of symptoms and are treated somewhat differently.

Major depression

Major depression is a combination of the symptoms listed above that is serious and long-lasting enough to interfere with daily life. It is also called unipolar depression. Major depression is the leading cause of disability in the United States and worldwide, because it can become severe enough to leave people unable to work, concentrate, learn, or care for themselves or their family. If left untreated, major depression can last for months or longer. Some people have only one period of major depression in their lives. For many others, however, episodes of major depression come and go for years.

Dysthymia

Dysthymia (dis-THI-mee-a) is the name given to a long-lasting depressed mood that is less severe than major depression, but which continues at a low level for a long time. People with dysthymia feel sad and show at least two other symptoms of depression for at least 2 years. Dysthymia often goes undiagnosed, because it is not disabling. However, it does leave people feeling sad and empty and keeps them from enjoying life and functioning at their best. Many people who have dysthymia also have episodes of major depression during their lives.

Bipolar disorder

Bipolar (by-POLE-are) disorder used to be called manic-depressive illness. It has two faces. One face is major depression. The other is mania (MAY-nee-a), an unnaturally high mood in which a person may be overactive, overtalkative, or filled with tremendous energy. The severe lows of depression alternate with the extreme highs of the manic phase. Symptoms of mania include:

• great energy; ability to go with little sleep for days without feeling tired
• severe mood changes from extreme happiness or silliness to irritability or anger
• overinflated self-confidence; unrealistic belief in one’s own abilities
• increased activity, restlessness, or distractibility; inability to stick to tasks
• racing, muddled thoughts that cannot be turned off
• impaired judgment of risk and increased reckless behavior.

For most people, the mood swings between depression and mania occur over a long period of time, sometimes years. If bipolar disorder is left untreated, though, the intervals between mood shifts tend to become shorter and shorter. In children, the cycle is usually quite short, sometimes occurring several times in a day.

Bipolar disorder is not as common as major depression. About 1 out of every 100 people has bipolar disorder, and unlike major depression, it occurs equally often in men and women. However, bipolar disorder appears to be more likely to run in families than major depression.

Adjustment disorder with depressed mood

It is not uncommon for people of all ages to respond to certain life stressors with emotional and behavioral symptoms. For example, someone may become depressed after losing a job or when a loved one has died. Another person may feel worried, anxious, or vulnerable after an injury or illness. A child or teen may have trouble concentrating in school or show some disruptive behavior in the months following his or her parents’ divorce.

When symptoms are too mild to be diagnosed as another mental health condition and occur as a reaction to a specific known life situation, the condition is called an adjustment disorder. Because people may react to difficult life circumstances with a variety of different types of emotions and behaviors, there are many types of adjustment disorders.

When the main symptoms of an adjustment disorder are depressed mood and related changes in feelings and behavior, such as feeling hopeless and crying a lot, the condition is called adjustment disorder with depressed mood.

With adjustment disorder, the symptoms are temporary and disappear within 6 months after the source of stress has been removed.

Seasonal affective disorder (SAD)

SAD is a form of depression that comes and goes at the same time each year, usually starting with the onset of winter. People with seasonal affective disorder often experience fatigue and oversleeping, carbohydrate craving and weight gain, as well as an overly sad mood. More women have SAD than men, and children and teens can also experience SAD. SAD is linked to decreasing exposure to daylight that occurs naturally during the winter months. Studies have shown that when people with this form of depression travel south in winter, their symptoms improve, and when they travel north their symptoms worsen.

These findings have led to treatment with artificial light. With light therapy, people use bright “grow-light” type lights or special lightboxes for several hours each day. This therapy has shown good results, and research continues to investigate this form of depression.

How Is Depression Treated?

Treatment for depression depends on its type and severity. There are several approaches that can be used either alone or in combination. Current thinking suggests that medication combined with psychotherapy (sykoe-THER-a-pea) is the most effective treatment for moderate to severe depression. The medication helps relieve the symptoms of depression, while the psychotherapy helps people change their negative thought patterns.

Medication

Antidepressant (an-tie-dee-PRESS-ant) medication can be prescribed by a psychiatrist (a medical doctor who specializes in mental disorders) or another physician. People usually must take a medication for several weeks before they notice changes in their mood, and they typically continue to take the drug for 6 to 9 months. Antidepressants are not habit-forming. Not every medication works for every person, however.

One group of antidepressants, introduced in the 1980s, is called selective serotonin (ser-o-TOE-nin) reuptake inhibitors (SSRIs). Serotonin is a neurotransmitter in the brain, and these drugs work by altering brain chemistry. They generally have fewer side effects than other drugs used to treat depression. Examples of SSRIs include fluoxetine (brand name Prozac), paroxetine (Paxil), and sertraline (Zoloft). Other types of antidepressants, including groups of drugs called monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), also can be helpful for some people.

Lithium (Eskalith, Lithobid) is a medication that can be very effective in treating bipolar disorder. However, lithium does not work for everyone. For these people, doctors sometimes prescribe another mood-stabilizing medication, such as carbamazepine (Tegretol) or divalproex sodium (Depakote).

St. John’s wort (Hypericum perforatum ) is an herb that is widely prescribed for mild depression in Europe. Although it is sold without a prescription in the United States, St. John’s wort has not been approved by the U.S. Food and Drug Administration for the treatment of depression, because not enough controlled studies have been done to show whether it is safe and effective. Those studies are currently underway.

Psychotherapy

Psychotherapy, or “talking therapy,” involves a therapeutic relationship between the depressed person and a psychiatrist, psychologist, or mental health counselor. Cognitive-behavioral (KOG-ni-tivbe-HAVE-yor-ul) therapy (CBT) and interpersonal (in-ter-PER-son-al) therapy (IPT) have been shown to be particularly useful. CBT focuses on helping people change their thoughts and actions. IPT helps people focus on resolving problems in relationships that may be triggers for depression.

Positron emission tomography (PET) records electrical activity inside the brain. With red and yellow showing brain activity, the brain of a depressed person at the top shows a decrease in activity compared to the brain of a person who has been treated for depression at the bottom. Treatment can improve metabolic acticity and blood flow in the brain. Photo Researchers, Inc.

Electroconvulsive (e-LEK-troe-kon-VUL-siv) therapy (ECT)

ECT, popularly known as “shock therapy,” is used to treat severe depression when immediate relief is needed. This treatment, which is performed by a physician, requires hospitalization and anesthesia to keep the person free of pain and injury. Carefully controlled electrical pulses are sent to the brain, causing a brief seizure. Although this treatment is controversial, it can be a lifesaver for someone who is suicidal and needs immediate relief.

Self-help groups

Many people experiencing depression find it helpful to join local support or self-help groups. These groups share information and tips for coping with depression. Some also offer support for close family members and friends.

Experiencing Depression

Sadly, about two-thirds of people who experience depression do not seek help. This is unfortunate, since the vast majority of people with depression can be helped to feel better in a relatively short time.

The best way to help someone with depression is to encourage that person to get professional help. If the depression is severe, encouragement may not be enough, however. It may be necessary to arrange a visit to a health care provider for them. Help is available through family physicians and health maintenance organizations, community mental health centers, hospitals, and mental health clinics. People who are talking about suicide need emergency care. Many telephone books list suicide and mental health crisis hotlines in their Community Service sections, or help can be obtained by calling emergency services (911 in most places).

Depression is not a sign of personal failure or something to be ashamed of. It does not mean that a person is “crazy.” Depression is simply an illness that needs to be treated so that life will once more be enjoyable, purposeful, and worthwhile.

See also

Bipolar Disorder

Brain Chemistry (Neurochemistry)

Genetics and Behavior

Seasonal Affective Disorder

Suicide

Therapy

Resources

Book

Styron, William. Darkness Visible: A Memoir of Madness. New York: Random House, 1990. A short book by the author of Sophie’s Choice about his battle with depression.

Organizations

American Psychiatric Association, 1400 K Street Northwest, Washington, DC 20005. A professional organization that provides information about depression on its website. Telephone 888-357-7924 http://www.psych.org

National Depressive and Manic-Depressive Association, 730 North Franklin Street, Suite 501, Chicago, IL 60610-7204. A national support organization for people with depression and bipolar disorder. Telephone 800-826-3632 http://www.ndmda.org/

U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8148, MSC 9663, Bethesda, MD 20892-9663. A government agency that does research on depression and provides information to the public through pamphlets and a searchable website. Telephone 800-421-4211 http://www.nimh.nih.gov