Depression

Depression is a mental health disorder characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities that were once enjoyable. It can also manifest as physical symptoms such as changes in appetite or sleep patterns, fatigue, and difficulty concentrating. Depression can vary in severity, from mild to severe, and it can significantly impact a person’s daily life, relationships, and overall well-being.

Some common symptoms and features of depression include:

Persistent low mood: Feeling sad, down, or empty for most of the day, nearly every day.
Loss of interest or pleasure: Losing interest in activities or hobbies that were once enjoyable.
Fatigue: Feeling consistently tired or lacking energy.
Changes in appetite or weight: Experiencing significant changes in eating habits and weight gain or loss.
Sleep disturbances: Having difficulty falling asleep, staying asleep, or sleeping too much.
Feelings of worthlessness or guilt: Having a negative self-image and experiencing excessive guilt or self-blame.
Difficulty concentrating: Finding it hard to focus, make decisions, or remember things.
Physical symptoms: Experiencing unexplained aches and pains.
Social withdrawal: Withdrawing from friends and family or experiencing difficulties in relationships.
Thoughts of death or suicide: Having thoughts of self-harm or suicide, or making suicide attempts.

Depression Is Different From Sadness or Grief/Bereavement

The death of a loved one, loss of a job or the ending of a relationship are difficult experiences for a person to endure. It is normal for feelings of sadness or grief to develop in response to such situations. Those experiencing loss often might describe themselves as being “depressed.”

But being sad is not the same as having depression. The grieving process is natural and unique to each individual and shares some of the same features of depression. Both grief and depression may involve intense sadness and withdrawal from usual activities. They are also different in important ways:

In grief, painful feelings come in waves, often intermixed with positive memories of the deceased. In major depression, mood and/or interest (pleasure) are decreased for most of two weeks.
In grief, self-esteem is usually maintained. In major depression, feelings of worthlessness and self-loathing are common.
In grief, thoughts of death may surface when thinking of or fantasizing about “joining” the deceased loved one. In major depression, thoughts are focused on ending one’s life due to feeling worthless or undeserving of living or being unable to cope with the pain of depression.

Grief and depression can co-exist For some people, the death of a loved one, losing a job or being a victim of a physical assault or a major disaster can lead to depression. When grief and depression co-occur, the grief is more severe and lasts longer than grief without depression.

Distinguishing between grief and depression is important and can assist people in getting the help, support or treatment they need.

Overview and Key facts

Depression is a common mental disorder.
Globally, an estimated 5% of adults suffer from depression.
More women are affected by depression than men.
Depression can lead to suicide.
There is effective treatment for mild, moderate and severe depression.

An estimated 3.8% of the population experience depression, including 5% of adults (4% among men and 6% among women), and 5.7% of adults older than 60 years. Approximately 280 million people in the world have depression (1). Depression is about 50% more common among women than among men. Worldwide, more than 10% of pregnant women and women who have just given birth experience depression (2). More than 700 000 people die due to suicide every year. Suicide is the fourth leading cause of death in 15–29-year-olds.

Although there are known, effective treatments for mental disorders, more than 75% of people in low- and middle-income countries receive no treatment (3). Barriers to effective care include a lack of investment in mental health care, lack of trained health-care providers and social stigma associated with mental disorders.

Symptoms

Although depression may occur only once during your life, people typically have multiple episodes. During these episodes, symptoms occur most of the day, nearly every day and may include:

Feelings of sadness, tearfulness, emptiness or hopelessness
Angry outbursts, irritability or frustration, even over small matters
Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports
Sleep disturbances, including insomnia or sleeping too much
Tiredness and lack of energy, so even small tasks take extra effort
Reduced appetite and weight loss or increased cravings for food and weight gain

Anxiety, agitation or restlessness
Slowed thinking, speaking or body movements
Feelings of worthlessness or guilt, fixating on past failures or self-blame
Trouble thinking, concentrating, making decisions and remembering things
Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
Unexplained physical problems, such as back pain or headaches

For many people with depression, symptoms usually are severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others. Some people may feel generally miserable or unhappy without really knowing why.

Depression symptoms in older adults

Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as:

Memory difficulties or personality changes
Physical aches or pain
Fatigue, loss of appetite, sleep problems or loss of interest in sex — not caused by a medical condition or medication
Often wanting to stay at home, rather than going out to socialize or doing new things
Suicidal thinking or feelings, especially in older men

Depression symptoms in children and teens

Common signs and symptoms of depression in children and teenagers are similar to those of adults, but there can be some differences.

In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.
In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using recreational drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.

Type of Depression

The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies depressive disorders as the following:

Clinical depression (major depressive disorder):

A diagnosis of major depressive disorder means you’ve felt sad, low or worthless most days for at least two weeks while also having other symptoms such as sleep problems, loss of interest in activities or change in appetite. This is the most severe form of depression and one

Persistent depressive disorder (PDD);

Persistent depressive disorder is mild or moderate depression that lasts for at least two years. The symptoms are less severe than major depressive disorder. Healthcare providers used to call PDD dysthymia.

Disruptive mood dysregulation disorder (DMDD);

DMDD causes chronic, intense irritability and frequent anger outbursts in children. Symptoms usually begin by the age of 10.

Premenstrual dysphoric disorder (PMDD):

With PMDD, you have premenstrual syndrome (PMS) symptoms along with mood symptoms, such as extreme irritability, anxiety or depression. These symptoms improve within a few days after your periodstarts, but they can be severe enough to interfere with your life.

Depressive disorder due to another medical condition:

Many medical conditions can create changes in your body that cause depression. Examples include hypothyroidism, heart disease, Parkinson’s disease and cancer. If you’re able to treat the underlying condition, the depression usually improves as well.

Seasonal affective disorder (seasonal depression):

This is a form of major depressive disorder that typically arises during the fall and winter and goes away during the spring and summer.

Prenatal depression and postpartum depression:

Prenatal depression is depression that happens during pregnancy. Postpartum depression is depression that develops within four weeks of delivering a baby. The DSM refers to these as “major depressive disorder (MDD) with peripartum onset.”

Atypical depression:

Symptoms of this condition, also known as major depressive disorder with atypical features, vary slightly from “typical” depression. The main difference is a temporary mood improvement in response to positive events (mood reactivity). Other key symptoms include increased appetite and rejection sensitivity.

Treatments for depression

There are various treatment options for depression. They include psychological treatments, medication and general measures such as relaxation techniques. Different treatment options are often combined.

Depression is one of the most common mental illnesses. During a depressive episode, people feel like they’re in a deep, dark pit for weeks or months, and often can’t see any way out. In chronic depression, the symptoms last for years. Treatment can shorten depressive episodes and relieve the symptoms.

What are the psychological treatment options?

Psychological treatment usually involves talking about things in depth and doing behavioral exercises. The kind of psychological treatment that is most commonly used for depression is known as cognitive behavioral therapy (often called “CBT” for short). Statutory health insurance companies in Germany cover the costs of CBT as well as other outpatient treatments, including depth psychology and systemic therapy. They are often offered by specially trained therapists.

If someone is going through an acute depressive episode, the doctor will usually recommend short-term psychological support, sometimes together with medication. Then you can apply for a full course of outpatient psychological treatment.

Cognitive behavioral therapy

In depression, negative thought patterns such as self-doubt and feelings of guilt often make the problem worse. Cognitive behavioral therapy aims to break these patterns bit by bit, so that people feel better about themselves.

Cognitive behavioral therapy combines two treatment approaches:

Cognitive therapy: Cognitive therapy is based on the idea that problems are often caused less by things and situations themselves, but rather by the importance that people attach to them. So changing the way people see things can be an important step.
Behavioral therapy: Behavioral therapy is based on the assumption that behavior is learned and can also be unlearned. The goal of behavioral therapy is to identify destructive patterns of behavior, then work at them and change them.

The goal of cognitive behavioral therapy is to become more aware of your own thoughts, attitudes and expectations. This makes it possible to identify false and distressing beliefs, and then change them.

Psychoanalytic approaches

Psychoanalytic approaches include analytical psychotherapy and methods based on depth psychology. They are based on the belief that unresolved, unconscious conflicts can cause depression. The aim is to identify and work through previously unknown issues by talking to a therapist. People who have psychoanalytic therapy have to be prepared to face potentially painful past experiences. Psychoanalysis usually takes longer than approaches based on depth psychology.

Systemic therapy

Systemic therapy approaches place a lot of importance on the relationships between people – for instance, within your family, your group of friends or at work. These relationships can play a role in the development of depression. The therapy might involve trying to improve communication within the family, for instance. The aim is to reduce the symptoms of depression.

Are there other treatment options?

Relaxation techniques and yoga

There is some evidence that relaxation techniques can help relieve mild to moderate depression. These include approaches such as progressive muscle relaxation, autogenic training, music therapy and yoga. But they aren’t as effective as other treatments, such as cognitive behavioral therapy. Psychotherapists sometimes teach relaxation techniques as part of the therapy, though.

Sports and exercise

Sports and exercise – such as Nordic walking, jogging, cycling, swimming or hiking – are often recommended for the relief or prevention of depression. Many people find that physical activity improves their mood and gives them more energy, and it has been found to help relieve depression in some people too. But research has also shown that physical activity doesn’t generally have a very big impact in people with depression. And there is little research on whether the benefits of exercise last in the longer term. Sports and exercise can be a useful addition to other treatments, though.

It is also not clear how much people might benefit from different types of sports and exercise. Physical activity might not necessarily be suitable for all types of depression either. For instance, people who have severe depression are often not capable of being physically active. Being advised to do more exercise might make them feel even worse.

Sleep deprivation therapy

This treatment involves temporarily depriving the patient of sleep. They stay awake for a whole night and only go to sleep the following night. It is thought that sleep deprivation changes the metabolism in the brain, and that this might lead to an improvement in mood. Sleep deprivation therapy only aims to improve the symptoms temporarily. It can be used in addition to other treatments.

Antidepressants

Various medications and groups of drugs are classified as antidepressants. They can have a mood-lifting effect and increase motivation. Antidepressants are often used in combination with psychological treatment. But it usually takes several days or weeks for antidepressants to start working. In acute depression they have to be taken every day for several weeks or months before they start having a noticeable effect. This is often followed by continuation treatment, which lasts four to nine months. How long people take medication for will depend on factors like their symptoms and their risk of having another depressive episode. Some people take antidepressants for years to prevent further depressive episodes.

The possible side effects of antidepressants include a dry mouth, headaches and feeling faint, restlessness and a decreased sex drive. These usually arise within the first few weeks of taking antidepressants. Whether or not someone has side effects, which side effects they have, and how frequent the side effects are will depend on the specific drug and dose that is used.

Different people react a bit differently to medication too. That’s why it’s important to see a doctor regularly while on medication, so they can see how things are going and adjust the treatment if necessary. Towards the end of the treatment, the dose of antidepressants is gradually reduced over the course of several weeks. If someone stops taking antidepressants suddenly, they might (temporarily) have problems sleeping, feel nauseous or restless. Stopping taking the medication as soon as you start to feel better without consulting your doctor can increase the risk of depressionreturning.

Electroconvulsive therapy

Electroconvulsive therapy is usually carried out in a hospital, under general anesthetic. Electrodes are placed on the patient’s head and a short burst of electric current is passed through the brain, inducing a seizure. The patient can’t feel anything because the procedure is carried out under general anesthesia. Electroconvulsive therapy is usually only considered as a treatment option for people with severe depression if other treatments haven’t helped.

How long does treatment last?

A distinction is made between different phases of treatment, referred to as “acute,” “continuation” and “maintenance” treatment (relapse prevention). Acute treatment usually lasts six to eight weeks. The aim is to

relieve symptoms enough to enable the person to cope in everyday life again, and
make the symptoms go away sooner, preventing the depression from further affecting their lives.

The next phase of treatment is called continuation treatment. This usually lasts four to nine months. The aim of continuation treatment is to

further relieve the symptoms, until they go away, and
sustain the progress made through treatment.

For people with a high risk of recurring depression, long-term treatment may be considered in order to prevent a relapse. This “relapse prevention” can sometimes last for years – for example, if the symptoms haven’t disappeared completely despite acute and continuation treatment, or if the patient’s personal circumstances are still very difficult. People who have chronic depression often take medication for many years too.