Feeling gloomy is a part of life for everyone, as we all experience the upside and downside of life. We all love and we all lose love. We get sick. Bad things happen like losing a job. Everyone takes it on the chin sometimes. For many people though, these temporary setbacks turn into a long-term problem. Major Depressive Disorder (MDD) is very common and can strike anyone at any time. Biological, psychological and social factors can cause depression.
5-10% of the worldwide population is having an episode of depression right now, approximately 121 million people. Individuals have a one in five chance of getting depression, and women are two times as likely to get depression as men. The World Health Organization predicts that the leading cause of disability by 2020 will be depressive disorder. The current annual economic burden of major depression in America is $100 billion.
The causes of depression are not completely understood. Some say that we have organized society away from a collective, or group living experience and this spawns loneliness and depression. Early life experiences of neglect, abuse or stress may make some people vulnerable. Genes and heredity play a part. Negative life events, physical illnesses, and substance abuse may trigger an episode of depression. Sometimes no identifiable cause is evident and this fact itself may cause a deepening of symptoms, as people want to find the cause and cannot. Depression can strike for no apparent reason.
Depression is clinically characterized by:
- chronic sad mood
- reduced energy
- loss of enjoyment in formerly positive activities
- low self-worth
- disturbed sleep or appetite
- low energy
- poor concentration
The severity of symptoms, the duration of symptoms and other issues inform physicians as they attempt to make an accurate diagnosis, begin effective treatment, and follow-up carefully. Suicidal ideation is a tangible possibly before, during, or after treatment, as depression claims 850,000 lives every year due to suicide. Many more attempt suicide. Most, but not all, patients benefit from psychotherapy and antidepressants. Since not all patients recover, no cure is considered to be found. Scientists are stilling uncovering causes and trying new treatments.
Negative and Positive Effects of Depression
Depressed people seem to get stuck and preoccupied in hopelessly distorted views and suffer from a lack of perspective. Faulty inferences are drawn through obsessional doubt and alienation from others’ thoughts and feelings. A hopeless and overwhelming reasoning process chips away at the ability to correctly perceive positive vs. negative conditions. Getting stuck on negative thoughts limits a person’s ability to find new and positive mindsets. Systematic cognitive negativity also impacts non conscious thoughts and behaviors.
However, negative moods also have value. A down mood may help people be less gullible and improve judgment in demanding and complex situations. Happy people tend to believe everything they are told but depressed people pay more attention, think more carefully, make less snap decisions and have better analytical reasoning and persistence. A positive mood is not always desirable.
Severe depression though, destroys the quality of life. A person’s ability to work and form relationships is hampered, and life may be cut short with depression causing physical illness and suicide. More consequences of depression include:
- Memory – deficits in activity in medial temporal and prefrontal lobe structures involved in memory retrieval.
- Risky Behaviors – promiscuity, improper condom use, and relationship violence is found in depressed people, including controlling relationships, rape, pregnancy and HIV.
- Relationships – individuals with depression do not make healthy partners in intimate situations as they are often withdrawn or even hostile. They show reduced ability to empathize with their partners.
Causes of Depression
Brain inflammation is strongly indicated in depression according to researchers. This new view adds to the current view and may oppose it. The current view states that serotonin and noradrenaline deficiencies cause the symptoms associated with depression. Since serotonin-based medicines do not cure all patients, another mechanism must be involved, study authors theorized. They found that patients with the highest levels of inflammation-related substances (cytokines) in their spinal fluid had been diagnosed with depression or had made suicide attempts. Efforts are underway to treat depressed patients with anti-inflammatory medications.
Authors believe that inflammation in the brain is the first step in a downward spiral of hormone depletion, including adrenaline and cortisol. People’s capacity to respond to stress is thereby lowered causing the emotional symptoms of depression. Inflammation causes a disruption in the natural self-regulating stress hormone activity. Some depressed people have higher than normal stress hormone levels while others have much lower levels. Researchers believe that this inconsistency is explained by looking at the long term. Chronic and long-term depressed people may have lower cortisol levels due to a ‘breakdown’ in the stress system.
In support of this new theory, recent studies have shown that leptin, a hormone secreted by adipose tissue or fat cells, and other locations, is less bio-available in obese people, indicating an inflammatory condition. Leptin also has effects on mood and stress pathways. After controlling for body weight, meaning that researchers discounted body weight data in their results, they found that women with the highest leptin levels also had the least severe symptoms of depression and anxiety. Leptin is considered an important mediator in modulating mood and those with high circulating concentration had decreased symptoms of anxiety and depression. Leptin therapy is in its infancy, with studies in leptin injections in humans underway.
Brain morphometry, or the shape and volume of the brain, shows deficits in certain brain regions in Bipolar disorder, which is remarkably similar to depression. Non-invasive neuroimaging techniques with Magnetic Resonance Imaging (MRI), CT scans, Magnetic Resonance Spectroscopy (MRS), Positron Emission Tomography (PET), and functional imaging (fMRI and fMRS) take 3D images of the brain.
Brain regions involved in mood regulation have reductions in size in bipolar patients. Bipolar is characterized by predominately depressive moods, with occasional manic moods. Bipolar patients had brain structure differences with cerebral volume reduction in the hippocampal and amygdala regions. Bipolar patients also show dysfunction in the prefrontal cortex, the region of the brain involved in emotion-processing and regulation, higher thought processing and goal planning. The work load that the prefrontal cortex can handle is therefore decreased. These areas of the brain do not work as “hard” as normal brains. Medications to increase volume deficits have shown significant results.
Disruptions in the biochemical substrates that help regulate mood is also seen in glutamate, myoinositol and choline. These substrates help with emotional expression and behavior. The body has a system of regulating and self-regulating the stress response. When inflammation disrupts the serotonin or 5-HT system, other helping bio-chemicals are disrupted downstream.
One study examined over 15,000 individuals and found a susceptibility gene for depression. SLC6A15, a gene that codes for a neuronal amino acid transporter protein, showed lower expression in majorly depressed patients. Researchers theorize that the low functioning gene conferred a risk and perturbed neuronal circuits. The circuit system in the brain neurons lacked integrity and had transmission deficits. Scientists say that this gene may be targeted with new pharmacological approaches.
Another gene called MKP-1 gene has recently been shown to be a major regulator of depressive symptoms. This gene showed two times the expression in the brain tissues of depressed patients. When researchers knocked out the gene in mice, the mice became resilient to stress. Since the gene may be overactive in depression, new drugs may be developed to block it or reduce the gene’s expression.
Chronic disease conditions can trigger depression, and depression may cause other debilitating conditions, slow recovery and lead to early death. People with chronic or acute diseases and depression show increased use of healthcare resources, including more physician visits, medication use, absenteeism from work and poor productivity.
- Stroke – depression develops in as many as a third of people who have had a stroke. Recovery from stroke is slowed as patient’s show functional deficits including bathing, getting dressed, eating and other tasks. Those who develop depression after a stroke are more likely to become dependent.
- Diabetes – the relationship between diabetes may work both ways as depression may cause diabetes and vice versa. Patients with both ailments face twice the risk of early death.
- Menopause – transitioning into the menopausal phase in life for women is known to be a high-risk period for major depression.
- Alzheimers – several studies have shown that having depression doubles the risk for developing dementia.
- Skin Conditions – the emotional strain of having a skin condition like psoriasis has adverse effects on mental health, initiating major depression and even suicide.
- Heart Disease – having depression and heart disease is a lethal combination. Depressed patients are more likely to develop heart conditions, and are five times more likely to die early.
- Postpartum – parents of either gender can develop depression after the birth of a child and women who have difficulties breastfeeding, or have urinary incontinence are more likely to develop depression. Parents who had an episode of postpartum depression also are more likely to have depressed children.
- Excess Body Weight – the overweight and obese are more likely to be depressed and losing weight can improve depressive symptoms. Also, treating depression may help increase a patient’s physical activity and help them lose weight.
- Cigarette Smokers – those with depression are not as able to quit smoking as much as non-depressed people. One in five depressed people quit smoking, whereas one in three non-depressed people succeed in abstaining from cigarettes.
- Body Dysmorphia – those with eating disorders, people undergoing plastic surgery and others with appearance dissatisfaction may have mental health problems. Anyone with a body tends to measure themselves against others, and a perceived low ranking may trigger depression.
- Internet Use – unreasonable use of the Internet is now identified as an addiction with psychiatric problems including relationship problems, aggressive behavior and poor physical health.
- Calorie Restriction – life longevity is increased when humans eat less than normal. However, some studies show calorie restriction can negatively affect mood.
- Bullying – victims of bullying, including children and adults, have elevated risk for depression and substance abuse in the short-term and long-term.
- Sexual Minority – orientation according to sexual preferences and preferences in intimate relationships can invite discrimination and victimization and lead to depression and suicide.
- Work – psychosocial job characteristics can trigger depression. Low ranking workers and workers in high risk jobs have higher rates of depression. 11% of firefighters are depressed which is higher than average.
- Temperments – certain personality traits and types may be more susceptible to affective disorders like depression.
- Perceived Powerlessness – perceptions of powerlessness or a lack of control over one’s environment may amplify depression.
- Unfullfilled Expectations – symptoms of depression may develop over the lifespan due to perceived inadequacies in educational attainment, employment, marriage, and parenthood.
- Circadian Preferences – professed “night persons” show more stress, depression, anxiety and substance abuse than “morning people.”
- Grief – loss of a partner is a main contributing factor to depression and this is true whether the loss is due to a breakup, divorce or death.
- Caregiving – emotional well-being is compromised in people who have to care for another due to physical or mental illness. In some cases, the stress may cause the caregiver to actually die before the person they are taking care of.
- Disasters – post disaster grief is common as people lose loved ones, property and experience powerlessness.
- Abuse – childhood abuse and abuse as an adult including physical violence, emotional abuse and neglect can trigger depression immediately or long after the events. The abuse negatively dominates expectations for the future.
- Night Eating – people with insomnia who get up and eat nocturnally have a high incidence of depression.
- Substance Abuse – depression may lead to substance abuse and/or struggles with street drugs, prescription drugs and alcohol. One study found that women with depression were four times more likely to use crack cocaine. Substance abuse and lack of success in quitting may lead to hopelessness and depression.
While women have a higher reported incidence of depression, males are more likely to use alcohol indicating sex differences in responding to stress. The effect of mother’s depression is well known, but new studies regarding depressed men report significant differences in the way depressed men interact with their children. Depressed men are reported to spank their children more and read books to them less.
The highest risk of depression is found in lowest income groups. The three psychopathologies of depression, suicidal ideation and suicidal attempt is more highly concentrated in low ranking socio-economic groups. Studies suggest that this risk is increasing over the past ten years, especially following recent economic crisis. Suicide especially is rising due to widening income inequalities.
Depression incidence is found in all countries and is especially correlated with being separated, divorced or widowed. Depression is found in greater incidence in high income countries, suggesting that income disparities maybe contribute to depression. High income countries have a certain percentage of people with high income, but with a significant portion of people being less advantaged. Median income countries have a lower incidence of depression, suggesting that income equality prevents depression to a certain extent. Very high income countries like France, the Netherlands, and America have the highest rates with over 30%. China has the lowest incidence at 12%.
- Elderly – personality types play a role in the development of depression in later life. Researchers believe that some personality types may be more resistant to stress. Elderly patients may not complain as much about low mood, but rather express dissatisfaction in complaints about physical issues.
- Children – tempermental differences can also be found in children as they respond to deficient parenting. Children low in fear respond to parental negativity with more depression. However, children low in control respond to poor autonomy granting and guidance by the parent by developing more depression and anxiety.
- Adolescents – the neuroendocrine response to stress is altered in adolescents as they cope with their history of physical, sexual or emotional abuse in childhood. The stress hormone cortisol is elevated in adolescents who were maltreated. They have pessimistic thoughts and think of death and self-harm.
Military & Veterans
Clusters of symptoms indicating post-traumatic stress disorder and depression is widely found in veterans of war and military service. These people re-experience trauma and react by avoidance, detachment, and numbing behaviors. Hopelessness and bodily disturbance symptoms are pervasive. Female veterans are more likely to seek treatment while African-Americans are more likely to seek religious counseling.
Treatment outcomes are better when depression is diagnosed in a timely fashion. While symptoms regarding mood are the most prominent method to diagnose depression, physical symptoms, especially in the young and old, may help find depression earlier. Declines in performance, difficulties in the tasks of daily living activities, verbal aggression, urinary incontinence, pain, and weight loss are significant clues as well.
Studies have indicated that health professionals are inadequately trained to spot mental health problems. One study found that nurses correctly identified depression only one quarter to one half of the time. This finding is also found in student health centers where one in four or five students have depressive symptoms that routinely go undiagnosed.
Researchers say that screening is simple, easy to do, and can save lives. People often have experienced a recent loss, trauma or other stressor. A family history of depression is easy to screen for as well as medical illnesses which are known to cause depression.
In addition to mood reports and behavior changes, tests of the chemical systems in the brain may more adequately diagnose depression. Analysis of blood and saliva samples can discover inflammation and cortisol deficiencies. Scientists are working to develop more physical tests which can lead to early diagnosis, better treatments and improved outcomes.
Other symptoms indicating depression:
- Avoidance of other people
- Avoidance of activities
- Feeling tired often
- Difficulty sleeping
- Poor appetite regulation; losing or gain weight
- Sexual dysfunction
- Poor concentration
- Difficulty making decisions
- Suicidal thoughts
Psychiatrists approach diagnosis with varying perspectives but generally use the Diagnostic and Statistical Manual (DSM) and the International Classification of Disease (ICD).
- Primary Depression – not caused by any other medical or psychological cause.
- Secondary Depression – caused by a medical condition or occurring with psychiatric illness.
Further differentiation includes separating mania, anxiety and psychosis (hallucinations and delusions). Some psychiatrists may further qualify depression due to hereditary factors or whether the depression was caused by a stressful life event. Many times a diagnosis of “mixed” depression is given when several factors are present.
Antidepressants that influence the serotonin (5-HT) system in the brain such as the selective serotonin reuptake inhibitors (SSRIs) are most commonly prescribed for depression. When symptoms are mixed, physicians may prescribe antidepressants and antipsychotic medication together. If anxiety is present, the type of antidepressant prescribed may differ. Symptoms of mania must be discovered as well, as antidepressant medication is not at all indicated for bipolar disorder.
Antidepressant medication acts to correct the ‘low’ mood by manipulating the uptake of the neurotransmitter serotonin. They do not produce a “high” feeling, change personality and are not addictive. Taking medication regularly for the prescribed time period should show improvement in two to four weeks. The World Health Organization suggests taking medication for six months to prevent a recurrence of the illness. Some people may have to take medication for a long time. Gradually reducing the dose rather than stopping abruptly is recommended. Discussing stopping your treatment with your doctor is the best course.
Classes of antidepressants includenew drugs that have fewer side effects than older drugs:
- Noradrenaline re-uptake inhibitors (NARIs)
- Noradrenergic and specific serotonergic antidepressants (NaSSAs)
- Reversible inhibitors of monoamine oxidase type A (RIMAs)
- Serotonin noradrenaline re-uptake inhibitors (SNRIs)
- Monoamine oxidase inhibitors (MOAIs)
- Selective serotonin re-uptake inhibitors (SSRIs)
- Tricyclic antidepressants (TCAs)
Non-Steroidal Anti-Inflammatory Medicines (NSAIDs)
Because the latest research shows that inflammation in the brain may be the first step in a cascade of negative physiological events, including deficits in serotonin, noradrenaline and cortisol, anti-inflammatory medications will likely see an increase in use.
Leptin replacement with injections of recombinant-methionyl-human leptin may also stop the inflammation in the brain that leads to serotonin and other hormone deficiencies. Natural therapies to increase leptin include getting proper sleep and eating anti-inflammatory foods.
Barriers to Treatment
As many as 40 percent of patients do not respond to medication. Stopping medications or taking medication inappropriately may reduce positive outcomes and cause a return of the symptoms of depression. Follow-up with the physician is important as the dosage may need adjustment or a different medication may need to be prescribed. Hospitalization may be required and people are highly encouraged to seek help, especially with suicidal thoughts.
- Psychotherapy – Talking to a trained counselor, along with medication improves the faulty inferences and negative thoughts that depressed people commonly have. The counselor will help to sort out work and family issues, grieving and loss, and previous health or emotional problems. There are many different kinds of psychotherapy and different kinds of counselors and professionals including cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT) and dynamic psychotherapy or psychoanalysis. Patients are encouraged to persist in finding someone to talk to, that they feel comfortable with. If one counselor does not suit, finding another is recommended. One form of therapy is not better than another but rather depends on the personalities of the therapist and patient meshing together.
- Family Approach – as depression has a hereditary basis, and stresses often happen within families, an intervention with family members can be very helpful. When one partner in an intimate relationship has depression, bringing the other part of the duo into the therapeutic relationship can increase positive outcomes.
- Social Buffering – loss of relationships is a very common trigger for depression onset. Therefore, seeking relationships and friendships can provide a positive buffering effect for symptoms. Support from family members, co-workers, religious counselors and informal networks are natural helpers to meet life satisfaction goals, especially in major depression.
Electroconvulsive therapy (ECT)
Patients with severe depression may elect to undergo electroconvulsive therapy (ECT) because it may work faster than medication. A small electric current is passed through the brain while the patient is sedated. ECT is only administered with an anesthesiologist, a psychiatrist and nursing staff. 6 to 10 treatments are commonly prescribed although benefits may be seen with one or two treatments.
- Exercise – produces a natural lift in mood, offers improvement in self- esteem and increases a sense of mastery and self-control. Any type of body treatment, including balance exercise and massage reduces tension, fatigue and anxiety.
- Nutrition – fish oil and other anti-inflammatory foods like berries, grains, legumes and green vegetables may significantly reduce depressive symptoms by reducing brain inflammation that leads to hormone insufficiencies.
- Sleep – hormone replenishment happens oftentimes at night. When sleep is disrupted, people often have depressive symptoms.
- Homeopathy – St. Johns Wort, and zinc supplements have been shown to have some effect in treating depression.
Patients had a major reduction in symptoms when a psychiatric nurse managed their care online. Messaging online delivered follow-up care without the wasted time required in trying to reach patients by telephone. Patients reported being very satisfied with asynchronous communication, took their medications more appropriately and had significant reduction in depressive symptoms.
Autogenic Training (AT)
A mind body technique which promotes relaxation has been found to improve insomnia, depression and anxiety. These body awareness exercises mediate the stress response and help release suppressed emotions. Participants in an eight week program showed significant improvements in depression scores.
Freshwater Snakehead Fish
Channa striatus, a Malaysian fish, has an antidepressant-like effect. The pharmacological effect of the fish is not well understood, so more studies are underway.
Positivity Activity Interventions (PAI)
PAIs are activities like counting one’s blessing, performing kind acts for others and practicing optimism. This new approach has no side effects, costs little and is not time-consuming. Researchers say that even brief positive activities can set off long-lasting improvements in mood.
Early diagnosis of depression is important as depression may cause debilitating and long-term medical issues like diabetes and hypertension. Modern statistical techniques with computers are increasingly being used to collect data and reveal patterns otherwise unnoticed. These data mining techniques can give new insights and customized approaches to physicians and patients.
Dysthymia – chronic mild depression distinguished by severity, number of symptoms, and the duration of symptoms. Dysthymia is diagnosed when symptoms do not rise to the level of a major depressive illness, but do have depressive symptoms for at least two years, with depression cycling a few days at a time. Full blown depression may develop and people should consider medication and psychotherapy.
Bipolar Disorder – this illness is characterized by mostly depressive symptoms and occasional or rapid cycling of manic episodes. Manic episodes are periods of elevated or “high” mood. Patients may behave irresponsibly, and engage in risky behaviors like gambling or promiscuity when in a manic phase. Many bipolar cases are misdiagnosed as depression because physicians fail to ask about moods that are opposite to depression. Treatment for bipolar does not include anti-depressant medication but instead anti-psychotic medications or hypnotic drugs.
Seasonal Affective Disorder (SAD) – a low mood in response to the onset of fall and winter seasons. Decreased sunlight is considered the main cause of this disorder, however decreased activities and social contacts in winter may also contribute to this transient depression. Sometimes, the holiday seasons in fall and winter may remind people of former losses they have experienced or lack of social support around the holidays. Antidepressants may help, along with counseling. Light therapy, or the use of a special lamp to approximate sunlight may help some cope.
Fatigue – a feeling of persistent tiredness may be confused with depression. Often, fatigue is due to physical or medical problems like infections, anemia, cancer and diabetes. Lack of exercise, diminishing muscle tone and poor diet can contribute to fatigue. Poor sleep and sleep apnea may produce a feeling of constant tiredness.
Dementia – confusion, poor memory and concentration difficulties may not be symptoms of depression, but rather cognitive deficits. Symptoms of dementia develop slowly over the years and the early stages of the disease may look a lot like depression.
Hypothyroidism – deficiencies in the hormones thyroxine (T4) and tri-iodothyronine (T3) secreted by the thyroid gland act to decrease metabolism. Lethargy and depression may result and is often misdiagnosed as primary depression. Blood tests should be ordered to rule out this disorder when depression is suspected.
Anxiety Disorder – persistent worrying or fearing, agitation, dread, irritability, racing heart, fast breathing and sweating are symptoms of anxiety. Anxious people may or may not be depressed as well.
Post-Traumatic Stress Disorder – people who have experienced or witnessed military combat, serious accidents, the violent death of others, torture, rape, or other crime can develop serious psychological problems. This disorder is distinguished from depression in that a triggering event is clearly evident.
Social Phobia – some individuals have trouble and anxiety related to socializing with others. They have irrational fears that everyone is looking at them and judging their performance. In response, they avoid social situations and fear those situations that they must engage in.
The main trigger for depression is loss of a relationship. When people lose friends, parents, grandparents, experience a romantic breakup, or become separated and divorced they can descend into sadness that cannot recover from by themselves. A loss of any kind, including job loss, having to drop out of school, an illness in loved one, or a loss of health in oneself can trigger a depressive episode. Changes in relationships, status or ranking also produce losses in a person’s sense of the future.
These losses induce changes in the way a person thinks. People perseverate or consistently reproduce negative thoughts that they play over and over again in their mind, like a broken record player. Their cognitive strategy becomes fixed and they find it difficult to break free. Their thoughts lead to maladaptive coping measures which cause further problems. They may withdraw from the people and activities which may be precisely the positive counteragents that they need. Relationships can become very strained as a depressed person shows decreased interest and misinterprets other’s emotions.
Pharmacological treatment to increase positive hormones, and psychological counseling can act to stop this downward spiral. Early diagnosis is important as chronic depression can cause serious medical problems, and many people end their lives with suicide. Prevention consists of forming strong social support to balance loss that everyone experiences in life. Natural prevention includes regular exercise, adequate nutrition and good sleep habits.
Depressive disorder is expected to become the leading cause of disability. Some social scientists believe that this epidemic is due to individualism or the lack of emphasis on group living. Humans are predominately social creatures, highly dependent on interactions with others. Lack of contact with others, superficial relationships, internet use, and disparity in socioeconomic status may explain the increasing incidence of depression.