Depression is a serious illness, but it can be successfully treated with the help of a health professional. If you think you are depressed. there are many places to get the help you need. You can:

• Call your family physician or other health care provider.

• Call your local health department, community mental health center, hospital, or clinic. They can help you or tell you where else you can go for help.

• Contact a local university medical center (many have special programs for the treatment of depression).

• Contact one of the national health groups listed below. They can refer you to a health professional where you live. They can also give you more information about depression, provide you with books and pamphlets, and tell you about support groups.

National Alliance for the Mentally Ill (NAMI)
2101 Wilson Blvd, Suite 302 Arlington, VA 22201
Toll free: 800-950-6264

National Depressive and Manic Depressive Association (NDMDA)
730 N. Franklin St., Suite 501 Chicago, IL 60610
Toll free: 800-82-NDMDA

National Foundation for Depressive Illness, Inc. (NFDI)
P.O. Box 2257 New York, NY 10116-2257
Toll free: 800-248-4344

National Mental Health Association (NMHA)
National Mental Health Information
Center 1021 Prince Street Alexandria, VA 23314-297 1
Toll free: 800-969-6642

A Patient's Guide

This information talks about major depressive disorder, which is only one form of depressive illness. If you are not sure that you have major depressive disorder, this may help to answer your questions and give you information.

There are two sections: Section 1 answers some of the common questions about depression and gives some basic information. Section 2 gives more detailed information about depression and its treatment. Use this information any way that will help you. You may want to: Print this information and take it with you when you Visit your health care provider. Your notes and records can help you get the best possible treatment for your depression. Share this information with a family member or close friend. It can help them to better understand your depression and its treatment.

This information is based on evaluation of research studies. Other treatments for depression that are available, while effective for some people, have not been carefully studied.

Here, the word "depression" is used to describe major depressive disorder.

Section 1

Who gets depressed?

Major depressive disorder--often referred to as depression--is a common illness that can affect anyone. About 1 in 20 Americans (over 11 million people) get depressed every year. Depression affects twice as many women as men.

What is depression?

Depression is not just "feeling blue" or "down in the dumps." It is more than being sad or feeling grief after a loss. Depression is a medical disorder (just like diabetes, high blood pressure, or heart disease are medical disorders) that day after day affects your thoughts, feelings, physical health, and behaviors.

Depression may be caused by many things, including:

Family history and genetics.
Other general medical illnesses.
Certain medicines.
Drugs or alcohol.
Other psychiatric conditions.

Depression is not your fault. It is not a weakness. It is a medical illness. Depression is treatable.

How will I know if I am depressed?

People who have major depressive disorder have a number of symptoms nearly every day, all day, for at least 2 weeks. These always include at least one of the following:

Loss of interest in things you used to enjoy.
Feeling sad, blue, or down in the dumps.

You may also have at least three of the following symptoms:

Feeling slowed down or restless and unable to sit still.
Feeling worthless or guilty.
Increase or decrease in appetite or weight.
Thoughts of death or suicide.
Problems concentrating, thinking, remembering, or making decisions.
Trouble sleeping or sleeping too much.
Loss of energy or feeling tired all of the time.

With depression, there are often other physical or psychological symptoms, including:

Headaches.
Other aches and pains.
Digestive problems.
Sexual problems.
Feeling pessimistic or hopeless.
Being anxious or worried.

What should I do if I have these symptoms?

Too often people do not get help for their depression because they don't recognize the symptoms, have trouble asking for help, blame themselves, or don't know that treatments are available.

Family practitioners, clinics, or health maintenance organizations are often the first places that people go for help. These health care providers will:

Find out if there is a physical cause for your depression.
Treat the depression.
Refer you to a mental health specialist for further evaluation and treatment.

If you do not have a regular health care provider, contact your local health department, community mental health clinic, or hospital. University medical centers also provide treatment for depression.

How will treatment help me?

Treatment reduces the pain and suffering of depression. Successful treatment removes all of the symptoms of depression and returns you to your normal life. The earlier you get treatment for your depression, the sooner you will begin to feel better. As with other medical illnesses, the longer you have the depression before you seek treatment, the more difficult it can be to treat.

Most people who are treated for depression feel better and return to daily activities in several weeks. Because it takes several weeks for treatment to work fully, it is important to get treatment early before your depression gets worse.

As with any medical condition, you may have to try one or two treatments before finding the best one. It is important not to get discouraged if the first treatment does not work. In almost every case, there is a treatment for the depression that will work for you.

What type of treatment will I get? The major treatments for depression are:

Antidepressant medicine.
Psychotherapy.
Antidepressant medicine combined with psychotherapy.

In some cases of depression. other treatments, such as electroconvulsive therapy (ECT) and light therapy, are also useful.

Thoughts of suicide or death are often a part of depression. If you have these thoughts, tell someone you trust now. Ask them to help you find professional help right away. Once your depression is properly treated, these thoughts will go away.

Who should see a mental health specialist?

Many people with depression can be successfully treated by their general health care provider. However, some people need specialized treatment because the first treatment does not work, because they need a combination of treatments, or because the depression is severe or it lasts a long time. Many times, a second opinion or consultation is all that is needed. If the mental health specialist provides treatment, it is most often on an outpatient basis (not in the hospital). If you think you need to see a mental health specialist, tell your health care provider, or contact one of the mental health organizations listed at the beginning of this document.

Section 2 will tell you more about depression, its diagnosis, and its treatment.

People Who Treat Depression

The following health care providers can treat depression:

General Health Care Provider

• Physician--A medical health care provider who has some training in treating mental or psychiatric disorders.

• Physician Assistant--An individual with medical training and some training in treating mental or psychiatric disorders.

• Nurse Practitioner--A registered nurse (R.N.) with additional nursing training and some training in treating mental or psychiatric disorders.

  The health care providers listed above can refer you to one of the health care providers specializing in mental health listed below:

  Mental Health Specialists
  

• Psychiatrist--A physician who specializes in the diagnosis and treatment of mental or psychiatric disorders.

• Psychologist--A person with a doctoral degree (Ph.D. or Psy. D.) in psychology and training in counseling, psychotherapy, and psychological testing.

• Social Worker--A person with a degree in social work. A social worker with a master's degree often has specialized training in counseling.

• Psychiatric Nurse Specialist--A registered nurse (R.N.) usually with a master's degree in psychiatric nursing who specializes in treating mental or psychiatric disorders.

Here, the term "health care provider" is used to describe any general health care provider or mental health specialist listed above.

Section 2

When someone is depressed, that person has several symptoms nearly every day, all day, that last at least 2 weeks. You can use the chart to check off any symptoms you have had for 2 weeks or more.

If you have some depressive symptoms, you should also tell your health care provider.

Sometimes a few symptoms can go on to become major depressive disorder. Some forms of depression are mild, but persistent or chronic. Chronic symptoms of depression also need treatment.

Another form of depression

Some people with depression have mood cycles. They have terrible "lows" (depression) and inappropriate "highs" (mania) that can last from several days to months. In between the highs and lows, they feel completely normal. This condition is called bipolar disorder or manic-depressive disorder.

Bipolar disorder affects about 1 in 100 people. Just as eye or hair color are inherited, bipolar disorder in most cases is inherited. It can also be caused by other general medical problems, such as head injury or neurologic or other general medical conditions.

You can use this list to learn the symptoms of mania and to check off any you might have.

If you have had four of these symptoms at one time for at least 1 week. including the first symptom marked with an asterisk(*), you may have had a manic episode. Tell your health care provider about the episode. There are effective treatments for this form of depression.

Causes of Depression

Major depressive disorder is not caused by any one factor. It is probably caused by a combination of biological, genetic, psychological, and other factors. Certain life conditions (such as extreme stress or grief) may bring out a natural psychological or biological tendency toward depression. In some people, depression occurs even when life is going well.

Drinking too much alcohol or using drugs can sometimes cause depression. When the drug and alcohol use is stopped, the depression usually goes away. Talk to your health care provider if you have a problem with drugs or alcohol. It can be treated.

Remember, major depressive disorder is not caused by personal weakness, laziness, or jack of will power, it is a medical illness that can be treated.

Diagnosing Depression

Before depression can be treated, it must be accurately diagnosed. Your health care provider will:

Ask about your symptoms.
Ask about your general health.
Ask about your family history of general medical and mental disorders. Give you a physical examination.
Conduct some basic laboratory tests.

Preparing For Your First Visit

You can help your health care provider diagnose and treat you by giving as much information as possible about your health. Write down some of that information. Information that you share with a health care provider is confidential.

If your depression is causing you to have a hard time talking and remembering, take a family member or friend along on your first visit to help.

A general medical history, physical examination, and basic laboratory tests can help find out if a general medical disorder is the cause of your depression. About 10 to 15 percent of all depressions are caused by general medical illness (such as thyroid disease, cancers, or neurologic diseases) or medicines. Once the condition is treated or the medicines are changed or adjusted, the depression will usually go away.

If you have a general medical illness and feel depressed, it is important to tell your health care provider. Sometimes depression is a reaction to a life-threatening condition. Getting help during a difficult time in your life may help you to cope with your general medical illness.

If your first episode of major depressive disorder occurred after age 40, a very thorough medical evaluation is important.

Severe? Moderate? Mild?

In the treatment section, the terms severe, moderate, and mild depression are used. In general...

Severe depression is present when a person has nearly all of the symptoms of depression, and the depression almost always keeps them from doing their regular day-to-day activities.

Moderate depression is present when a person has many symptoms of depression that often keep them from doing things that they need to do.

Mild depression is present when a person has some of the symptoms of depression and it takes extra effort to do the things they need to do.

For each type of depression there is a treatment that works best. You should talk with your health care provider about your depression and the best treatment for you.

Treating Depression

Depression is usually treated in two steps.
First: Acute treatment.
Second: Continuation treatment.

The aim of acute treatment is to remove the symptoms of depression until you feel well. Continuation treatment (continuing the treatment for some time even after you are well) is important because it keeps the episode of depression from coming back. Depending on the type of treatment you have, your chances of staying well for 6 months on continuation treatment are extremely good.

In cases of recurrent depression (three or more episodes), a third step, called maintenance treatment, is used to treat the depression. In maintenance treatment, you stay on the treatment for a longer period of time. The purpose of maintenance treatment is to prevent a recurrence of the depression. With maintenance treatment, the chances of staying well are also extremely good.

The major types of treatment for depression are:

Antidepressant medicine.
Psychotherapy.
Antidepressant medicine combined with psychotherapy.
Other treatments, including electroconvulsive therapy (ECT) and light therapy.

For severe depression, research studies show hat medicine is very effective. Psychotherapy s not been well studied for the more severe forms of depression.

How Treatment Works

Treatment for depression works gradually over several weeks. With medicine, most people see some benefits by 3 or 4 weeks: with psychotherapy alone, it can sometimes take longer. There is a very good chance that your first treatment will work well for you. If treatment is not effective after a certain amount of time, it can be changed or adjusted. There are other treatments to try, and your chances for effective treatment are still very good.

Choosing a Treatment

You and your health care provider can work together to find the best treatment for you. In choosing which acute treatment is best for you, you should weigh the chances of getting better (benefits) against the chances of possible harms, as well as the expense of the treatment offered and the costs of the depression (time from work, effect on personal relationships, etc.) Here are some questions you may want to ask when discussing treatment.

1. What are the chances of getting better with this treatment?

2. What are the possible risks and side effects of treatment?

3. What are the costs of treatment?

About Hospitalization

Most people with depression get their treatment through regular outpatient visits to a health care provider. However, sometimes treatment in the hospital is needed. This is because other medical conditions could affect your treatment. Another reason is that people with severe depression may need hospital care (for example, to adjust medicine). Also, people who are at great risk for suicide are hospitalized until those feelings pass and treatment begins to work.

If you must go to the hospital for treatment, it is often only for a few days or a week or two. Early treatment, before the depression becomes severe or chronic, can lower the chances of hospitalization.

Why Depression Must be Treated

Without treatment, a major depressive episode can last 6 to 12 months. In between the episodes, most people feel better completely well (without symptoms). or are Even though some people are able to struggle through an episode of depression without treatment, most find that it is much easier to get some help for their pain and suffering. It is important to get treatment for your depression because:

Early treatment may help to keep the depression from becoming more severe or chronic.

Thoughts of suicide are common in depression, and the risk of suicide is increased when patients are not treated and the depression recurs. When depression is successfully treated, the thoughts of suicide will go away.

Between episodes, about 1 out of 4 people with depression will still have some symptoms and trouble doing their daily activities. These people, if not treated, have a greater chance of having another episode of depression.

Treatment (especially medicines)can prevent recurrences of depression. The more episodes of depression you have had, the greater the chance that you will have another. About half of the people who have one episode of depression will have a second. Without treatment, after two episodes, the chances of having a third episode (recurrent depression) are even greater. After three episodes, the chances of having a fourth are 90 percent.

If You Have Concerns About Your Treatment

If at any time you are worried about your treatment or you don't think that things are going well, tell someone about your concerns. You can:

Talk to your health care provider.
Ask for a second opinion.
Talk to someone you trust.

Health care providers are interested in your concerns and will help you. This may mean getting a second opinion or even finding another health care provider.

Antidepressant Medications

There are many different types of antidepressant medicines that can be used to treat depression. Each of these types of medicine work a little differently. Your symptoms, medical history, and family history often give clues about the best medicine for you. Still, it may take some time to find the one that works best for you and has the least side effects. Together, you and your health care provider will find the exact type and amount of medicine that you need.

Antidepressant medicines are not addictive or habit forming. They work in severe depression and may be useful in mild to moderate depression.

Many people begin to feel the effects of medicine even in the first few weeks of treatment. After about 6 weeks, more than half of the people who begin antidepressant medicine will feel more like their usual self.

At the beginning of treatment, your health care provider will want to see you more often (possibly every week). The purpose of these visits is to check the dosage (how much and how often you take the medicine), to watch for side effects (problems caused by the medicine), and to see how the treatment is working on your depression.

Once you begin to feel better, you probably will visit the health care provider less often. In continuation treatment. you will probably visit your health care provider every month or two. In maintenance treatment, visits are usually every 22 to 3 months.

You will get the most help from your treatment if you do five things:

1.. Keep all of your appointments.
2. Ask questions.
3. Take your medicine as your health care provider tells you.
4. Tell your health care provider right away about any side effects you have.
5. Tell your health care provider how the medicine is working.

Keep all of your appointments whether you are feeling better or worse. If you are taking antidepressant medicines, you must keep all of your appointments to check the dosage and watch for side effects. It may help to keep a record of this information.

Ask questions. Talk to your health care provider if you have concerns about the medicine. The answer to some of your questions may help you and your health care provider to choose the treatment that is best for you personally. Remember: There is no such thing as a "dumb" question when it comes to your health.

Take your medicine as directed, even when you begin to feel better. It is important to continue to take the medicine in order to keep feeling well. You may want to write down the name of the medicine you are taking.

Tell your health care provider right away about any side effects you have. Even though all medicines have some side effects, not all people get them. Some patients have different side effects than others. With antidepressant medicines, up to half of the people have some side effects early in treatment (in the first 4 to 6 weeks). Side effects are usually not a problem after that. For a small number of people, side effects are bad enough to stop the medicine.

The side effects you might get depend on many things. These are:

The type and amount of medicine you take.
Your body chemistry.
Your age.
Other medicines you take.
Other medical conditions you may have.

If side effects are a problem for you, there are a number of things your health care provider can do. Changes can be made in:

The amount of medicine you take. Sometimes side effects can be lessened by reducing the amount of medicine you take.

The type of medicine you take. Your health care provider may try a different medicine to see if there are fewer or less bothersome side effects.

The time of day you take your medicine. Sometimes side effects can be lessened by taking medicine at night instead of in the morning.

How the medicine is taken. Your health care provider may suggest dividing a single daily dose into smaller amounts to take more than once a day.

Changing medicine is a complicated medical decision, It is dangerous to make changes in your medicine your own!

Here are some common side effects of antidepressant medicines:

Dry mouth.
Dizziness.
Constipation.
Skin rash.
Sleepiness.
Trouble sleeping.
Weight gain/loss.
Restlessness.

More serious side effects are rare. As with minor side effects, they usually happen in the first few weeks of treatment. They include difficulty passing urine, heart trouble, sexual problems, seizures, fainting, or other effects. Both the common and rare side effects are nearly always treatable.

If you are having side effects, call your health care provider. Do not wait for the next appointment.

About 1 in 10 people who have a close relative with bipolar disorder can develop manic symptoms in the first few weeks of taking the medicine. Only a very small number (1 or 2 out of 100) of people without a relative with bipolar disorder experience manic symptoms when taking antidepressant medicine. An early sign that manic symptoms may be coming is that vou feel that you have a lot of energy or feel very "high" or euphoric. Tell your health care Provider about these changes right away.

Tell your health care provider how the medicine is working. One way to know how the medicine is working is to keep a record of your symptoms. If the medicine is not working for you (your symptoms are getting worse or not getting better), your health care provider may recommend a blood test to see whether you are getting the right amount of medicine in your body.

There are many things that can be done if the medicine is not working. These are:

Adjust the dose.
Change the medicine.
Add psychotherapy.
Add a medicine.

Feeling Better

Continuation treatment. Once you are feeling better for awhile, you and your health care provider will decide if this episode of depression has ended. In most cases, you should continue to take the antidepressant medicine for several months. Research clearly shows that continuation treatment with medicine helps prevent a relapse (a return) of the depressive episode.

After 4 to 9 months of continuation treatment, if you continue to feel good, you have recovered from this episode of depression. If you have had only a single episode of depression, continuation treatment can be stopped with a good chance that you will remain well. Nearly all patients who are on continuation treatment will stay well during that time.

Maintenance treatment. Some people with depression need maintenance (long-term) treatment. If you have had at least three episodes of depression or if you have bipolar disorder, you will need maintenance treatment to stay well. Research clearly shows that maintenance treatment with medicine prevents a new episode of depression. Some antidepressant medicines have been used by patients for 30 or more years with no bad effects. Before starting maintenance treatment, you and your health care provider should discuss its costs and benefits.

The aim of acute treatment with psychotherapy alone is to remove all symptoms of depression and return you to your normal life. In psychotherapy, you work with a qualified health care provider (therapist) who listens, talks, and helps you solve your problems. Psychotherapy is usually brief and often has a time limit (for example, 8 to 20 visits).

Types of Psychotherapy Psychotherapy can be individual (only you and a therapist); it can be group therapy (with a therapist, you, and other people with similar problems); or it can be family or marriage therapy (with a therapist, you, and family members, loved ones, or spouse).

Your health care provider will help you decide if psychotherapy is the right treatment for your depression. Three psychotherapies have been most well studied for their effectiveness in reducing symptoms of major depressive disorder. They are:

Behavioral therapy--focuses on current behaviors.
Cognitive therapy--focuses on thoughts and beliefs.
Interpersonal therapy--focuses on current relationships.

Psychotherapy alone is not recommended as the only treatment for severe depression or for bipolar (manic-depressive) disorder. Medicine is needed for these types of depression.

Choosing Psychotherapy

If you choose psychotherapy you need to:

Keep your appointments.
Be honest and open.
Try to do the tasks if assigned to you as part of your therapy.
Tell your health care provider how the treatment is working.

The cognitive, behavioral, and interpersonal therapies usually work gradually. Although psychotherapy may begin to work right away, for some people it may take 8 to 10 weeks to show a full effect. More than half of the patients with mild to moderate forms of major depression respond well to psychotherapy.

As with medicine, it is important to remember that people can react differently to similar treatments. While many people find psychotherapy effective, others do not. This usually means that another treatment is needed.

If you do not feel any better at all after 6 weeks, or if you are not completely well by 12 weeks. talk to your health care provider about other treatments.

Continuation psychotherapy. If your depression gets better with psychotherapy. you and your health care provider can decide if your therapy should continue and for how long.

Maintenance psychotherapy. In general, maintenance (long-term) psychotherapy by itself is not recommended unless there are reasons. such as pregnancy or severe side effects, that keep you from taking medicine. While maintenance psychotherapy does not prevent another episode of depression, some research suggests that it can delay a recurrence.

Combining Medicine and Psychotherapy

In combined treatment, medicine is used to treat the symptoms of depression, and psychotherapy is used to help with ways in which depression causes problems in your life. Some people find that combining treatment is very helpful. With combined treatment, more than half of the patients feel better after 6 to 8 weeks. Combined treatment may be most helpful for longer lasting depression, for those with symptoms between episodes, or for those who do not respond fully to medication or psychotherapy alone.

Electroconvulsive Therapy

Most depressions, even severe depressions, can be treated completely with medicine, psychotherapy, or the combination of both. Electroconvulsive therapy (ECT) works to remove the symptoms of depression. It is mostly used for severely depressed patients who have not responded to antidepressant medicines. It can also be used for patients who are severely depressed and have other severe general medical illnesses. ECT is much safer than in years past. General anesthesia and special muscle relaxing medicines are used to prevent physical harm and pain during the ECT. The choice of ECT as a treatment and the possible side effects should be discussed with a psychiatrist. As with other treatments, the psychiatrist will monitor the ECT treatment and check for side effects.

In light therapy, a special kind of light called broad-spectrum light is used to give people the effect of having a few extra hours of daylight each day. Specially made light boxes or light visors are used to provide this light. Light therapy may help peopIe who have mild or moderate seasonal depression. This treatment should only be given by a specialist until it has been studied more thoroughly.

When you are depressed, it is important to:

Pace yourself. Do not expect to do all of the things you were able to do in the past. Set a schedule that is realistic for you.

Remember that negative thinking (blaming yourself. feeling hopeless, expecting failure, and other such thoughts) is part of a depression. As the depression lifts, the negative thinking will go away, too.

Avoid making major life decisions during a depression. If you must make a major decision about your life, ask your health care provider or someone you trust to help you.

Avoid drugs and alcohol. Research shows that drinking too much alcohol and use of drugs can cause or worsen a depression. It can also lower the effectiveness of antidepressant medicines or cause dangerous side effects.

Understand that it took time for the depression to develop and it will take time for it to go away.

There is some evidence in milder cases of depression that exercise can be a helpful addition to treatment.

You can get information about other ways to help yourself during treatment from the organizations listed on the inside front cover of this booklet. Your public library also has books about depression.

Benefits and Harms of Treatment

The treatments for major depressive disorder discussed in detail here are:

Antidepressant medicine.
Psychotherapy.
Antidepressant medicine combined with psychotherapy.

How well each of these treatments works depends on the type of depression, how severe the depression is, how long you have been depressed, how you as an individual may react to treatment. and other factors. The risks and benefits described below are based on current medical knowledge using studies of large numbers of depressed patients and expert opinion.

Talking to Others About Depression

When people have major depressive disorder, they often have difficulty at work, school, and with family members. With treatment, almost everyone returns to their normal life.

Some jobs (where the safety of others is involved) require that you report treatment for medical illnesses (including depression ). You and your health care provider should talk about how and what to tell your supervisor, teacher, or friends.

Ask your friends for their support, understanding, and patience during your depression. It may be helpful to talk to your friends about your feelings and treatment and to spend time with friends in social activities. Keep the name and phone number of people that you can talk to and to ask to help you. Some people with depression find it difficult to be with others during this time. If you feel this way, do whatever lifts your mood and makes you reel better. If you find yourself alone and unable to be with others, tell your health care provider. Many people find that family members are very supportive and helpful. especially those who have received education about depression.

Parents often worry about whether depression is inherited. Most children of people with depression will not get this illness. Overall, research shows that only about 1 in 7 children with one parent who has had several episodes of major depressive disorder or bipolar disorder will develop major depressive disorder. Another 1 in 7 children with one parent who has bipolar disorder will develop bipolar disorder. If you have questions about your child's mental health talk to a health care provider.

In addition to the organizations listed at the beginning of this article, the National Institute of Mental Health, has free publications about depression for persons of all ages, including teenagers and the elderly. Write:

Depression Awareness, Recognition, and Treatment (DART) Program
Department GL, Room 10-85
5600 Fishers Lane
Rockville, MD 20857
Toll free: 800-421-4211

The information contained here was taken from the Clinical Practice Guideline on Depression in Primary Care, Volumes I and 2. The guideline was developed by a private, non-Federal expert panel of physicians, psychologists, psychiatrists, social workers, nurses, counselors, and persons who have depression. The development of the guideline was sponsored by the Agency for Health Care Policy and Research (AHCPR), an agency of the U.S. Public Health Service. Other guidelines on common health problems are being developed and will be released in the near future.

To receive additional copies of this article or the depression guidelines call: Toll free: 800-358-9295 or write:

AHCPR Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907

April 1993