“The grey drizzle of horror,” author William Styron memorably called depression. The mood disorder may descend seemingly out of the blue, or it may come on the heels of a defeat or personal loss, producing persistent feelings of sadness, worthlessness, hopelessness, helplessness, pessimism, or guilt. Depression also interferes with concentration, motivation, and other aspects of everyday functioning.

According to the World Health Organization, depression is the leading cause of disability worldwide. Globally, more than 300 million people of all ages suffer from the disorder. And the incidence of the disorder is increasing everywhere. Americans are highly concerned with happiness, yet they are increasingly depressed: Some 15 million Americans battle the disorder, and increasing numbers of them are young people.

Depression comes in forms ranging from major depression to dysthymia and seasonal affective disorder. Depressive episodes are also a feature of bipolar disorder.

Depression is a complex condition, involving many systems of the body, including the immune system, either as cause or effect. It disrupts sleep and it interferes with appetite; in some cases, it causes weight loss; in others, it contributes to weight gain. Depression is also often accompanied by anxiety. Research indicates that not only do the two conditions co-occur but that they overlap in vulnerability patterns.

Because of its complexity, a full understanding of depression has been elusive. There is mounting evidence that depression may actually be a necessary defense strategy of the body, a kind of shutdown or immobilization in response to danger or defeat, that is actually meant to preserve your energy and help you survive.

Researchers have some evidence that depression susceptibility is related to diet, both directly—through inadequate consumption of nutrients such as omega-3 fats—and indirectly, through the variety of bacteria that populate the gut. But depression involves mood and thoughts as well as the body, and it causes pain for both those living with the disorder and those who care about them. Depression is also increasingly common in children.

Even in the most severe cases, depression is highly treatable. The condition is often cyclical, and early treatment may prevent or forestall recurrent episodes. Many studies show that the most effective treatment is cognitive behavioral therapy, which addresses problematic thought patterns, with or without the use of antidepressant drugs. In addition, evidence is quickly accumulating that regular mindfulness meditation, on its own or combined with cognitive therapy, can stop depression before it starts by diminishing reactivity to distressing experiences, effectively enabling disengagement of attention from the repetitive negative thoughts that often set the downward spiral of mood in motion.

Depressive Disorders

Depressive disorders are characterized by persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities. Depression is not a passing blue mood, which almost everyone experiences from time to time, but a complex mind/body illness that interferes with everyday functioning. It not only darkens one’s outlook, it is commonly marked by sleep problems and changes in energy levels and appetite. It alters the structure and function of nerve cells so that it disrupts the way the brain processes information and interprets experience. Despite feelings of hopelessness and worthlessness, depression is a treatable condition. It can be treated with psychotherapy or medication, or a combination of both.

Depression is a common condition in modern life. According to the National Institutes of Health, each year more than 16 million adults in the United States experience at least one episode of major depression. The likelihood that a person will develop depression at some point in life is approximately 10 percent. Prolonged social stress and major disruption of social ties are known risk factors for depression, and major negative life events such as loss of a loved one, or loss of a job, increase the subsequent risk of depression. Significant adversity early in life, such as separation from parents or parental neglect or abuse, may create vulnerability to major depression later in life by setting the nervous system to over-respond to stress.

Definition

A depressive disorder is a condition that involves the body, mood, and thoughts. It disables motivation and interferes with normal functioning of daily life. It typically causes pain both to the person experiencing the mood disturbance and those who care about him or her.

A depressive disorder is not the same as a passing blue mood—by definition, the symptoms must be present for at least two weeks. Nor is it a sign of personal weakness or a condition that can be willed or wished away. Depression tends to be episodic, with bouts lasting weeks or months. Although symptoms tend to remit spontaneously over time, some form of treatment is important to reduce the likelihood of recurrent episodes. Appropriate treatment can help most people who suffer from depression.

Depressive disorders come in different forms, as is the case with other illnesses such as heart disease. Three of the most common types of depressive disorders are described here. However, all forms are marked by variation in the number of symptoms as well as their severity and persistence.

Major depressive disorder, or major depression, is manifested in a persistently sad mood accompanied by a number of other symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. A disabling episode of depression may occur only once but more commonly occurs several times in a lifetime. Depression is more than a disorder only from the neck up. It also affects the function of many body systems. Researchers have established, for example, that immune function is often compromised in depressive states, and impaired immune function may in part underlie the link of depression to such other disorders as heart disease.

Dysthymic disorder, or persistent depressive disorder, also called dysthymia, involves symptoms of sad or down mood most days for most of the day over a long term (two years or longer) but the depressed mood is not disabling, although it impairs functioning to some degree. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Some forms of depressive disorder involve slight variation of features or develop under specific circumstances.

Premenstrual dysphoric disorder manifests in the week before the onset of menses, subsides within days after onset of menstruation, and remits in the week after menstruation. According to the National Institutes of Health, 3 to 8 percent of women of reproductive age meet strict criteria for premenstrual dysphoric disorder.

Major depression with psychotic features, or psychotic depression, occurs when a severe depressive illness is accompanied by delusions and hallucinations, The psychotic features may be mood-congruent with the depression—that is, consistent with the depressive themes of personal inadequacy, guilt, nihilism, or death. Or the delusions and hallucinations may be mood-incongruent, not involving such depressive themes.

Major depression with postpartum onset, or postpartum depression, is diagnosed if a woman develops a major depressive episode during pregnancy or within four weeks after delivery. It is estimated that 3 to 6 percent of women experience postpartum depression.

Major depression with seasonal patterns, or seasonal affective disorder (SAD), is characterized by the onset of a depressive illness during particular times of the year. Typically, the depression develops during the winter months, when there is limited natural sunlight, and completely remits in the spring and summer months. In a minority of cases of major depression with seasonal patterns, the depression occurs during the summer months. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Symptoms

The following signs and symptoms are catalogued by the DSM-5 as signifiers of major depressive disorder and at least five must be present during the extended period of low mood or loss of pleasure in once-enjoyable pursuits. Not everyone experiences every symptom, nor do people experience the same symptoms to the same degree. Symptoms may vary not only between individuals and but over time in the same individual.

• Persistent sad, anxious, or empty mood most of the day, most days
• Feelings of worthlessness or excessive guilt
• Loss of interest or pleasure in activities that were once enjoyed, including sex
• Persistent loss of energy or fatigue
• Difficulty thinking, concentrating, remembering, or making decisions
• Insomnia, early morning awakening, or oversleeping (hypersomnia)
• Significant change in appetite resulting in unintended weight loss or weight gain
• Observable psychomotor agitation or restlessness, or psychomotor slowing
• Feelings of hopelessness or pessimism; recurrent thoughts of death or suicide, suicide attempts

Causes

There is no single cause of depression. Rather, evidence indicates it results from a combination of genetic, biologic, environmental, and psychological factors.

Research deploying brain-imaging—such as magnetic resonance imaging (MRI)—and other technologies shows that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. But these changes do not reveal why the depression has occurred.

There are many pathways to depression. Genetic factors may play a complex role in setting the level of sensitivity to certain kinds of events, including the level of nervous system reactivity to stress and other challenges. Scientists know there is no single gene involved: many genes likely play a small role in contributing to vulnerability; acting together with environmental or other factors.

However, depression can occur in people without family histories of it as well. There is significant evidence that harsh early environments—especially experiences of severe adversity such as abuse or neglect in childhood—can create vulnerability to later depression by altering the sensitivity of the nervous system to distressing or threatening events.

Experiences of failure, rejection, social isolation, loss of a loved one, or frustration or disappointment in achieving relationship or any other life goal often precede an episode of depression. For that reason, many researchers regard the negative mood state of depression as a painful signal that basic psychological needs are not being met and that new strategies are needed. They also suggest that depression to some degree results from a lack of skills in processing negative negative feelings; some of the most effective therapies for depression teach what can be considered basic mental hygiene, cognitive and emotional tools for dealing with negative feelings. Trauma, which can overwhelm emotional processing mechanisms, is another common trigger for depressive episodes.

Depression in Women

Women experience depression about twice as often as men. Biological, life cycle, hormonal, and other factors—including experiential ones—unique to women may be linked to their higher depression rate. Researchers have shown that hormones directly affect brain regions that influence emotions and mood, and they are further exploring how hormone cycles can give rise to depressive states. Some women may be susceptible to the severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD). Women are also vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a helpless infant can be overwhelming. Many women also uniquely face such proven chronic stresses as juggling work and home responsibilities, single parenthood, domestic abuse, and caring for children and aging parents.

Ongoing research probes why some people faced with enormous challenges develop depression, while others with similar challenges do not.

Depression in Men

Millions of men in the U.S. and around the world also suffer the psychic pain of depression. Research and clinical evidence establish that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.

Depression can also affect the physical health in men differently from women. One study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men experience an elevated death rate.

Instead of acknowledging their feelings or seeking help in the form of appropriate treatment, men may turn to alcohol or drugs when they are distressed. They may also be angry, irritable, and, sometimes, violently abusive. Some men deal with emotional distress by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm’s way.

More than four times as many men as women die by suicide in the U.S., even though women make more suicide attempts during their lives. In light of the research indicating that suicide is often associated with depression, the high suicide rate among men may reflect the fact that many men with depression do not seek adequate diagnosis and treatment.

Encouragement and support from concerned family members can be lifesaving. In the workplace, employee assistance programs or worksite mental health programs can be particularly important n helping men understand depression as a real disorder that needs treatment.

Depression in the Elderly

Contrary to some popular thinking, depression is not a normal accompaniment to aging. On the contrary, older people tend to experience rising levels of satisfaction with their lives. However, when older adults do develop depression, the condition may be overlooked because it can manifest less in feelings of sadness or grief and more in irritability or general apathy or feelings of tiredness. Also, depression tends to affect memory, and in the elderly depression can show up as confusion or problems with attention. Aging brings many life changes that can be triggers for depression, including loss of a loved one, loss of employment and sense of purpose, loss of robustness or good health.

In addition, medical conditions that occur more frequently with age, such as heart disease, stroke, and cancer, may cause depressive symptoms. Or the medications used for such conditions may carry side effects that contribute to depression.

There is a type of depression that develops in late life, known as vascular depression, sometimes also called arteriosclerotic depression or subcortical ischemic depression. It results from cerebrovascular damage that occurs with cardiovascular disease. Brain-imaging studies show that areas of blood vessel damage restrict blood flow to regions of the brain involved in emotion and mood regulation or to the brain’s white matter. Those who develop vascular depression often have a history of hypertension, or high blood pressure. Vascular depression may manifest in paranoia, aggressive tendencies, or apathy and slowing of movement. There are deficits in executive function. Diagnosis may involve magnetic resonance imaging (MRI) to detect vascular pathology in specific parts of the brain. Vascular depression tends not to respond to antidepressant medication; instead, the first line of approach may be forms of psychosocial support and/or cognitive behavioral therapy.

The majority of older adults with depression improve when they receive treatment with psychotherapy, antidepressant medication, or a combination of the two. Research has shown that psychotherapy alone can be effective in prolonging periods free of depression.

Treatment

Depression, even in the most severe cases, is a highly treatable disorder. The sooner treatment begins, the more effective it is and the greater the likelihood that recurrence can be prevented.

Appropriate treatment for depression starts with a physical examination by a physician. A number of medications, as well as some medical conditions, including viral infections and thyroid disorder, can cause depression-like symptoms and must be ruled out. Once a physical cause of depression is ruled out, a psychological evaluation can be conducted, either by the examining physician or via referral to a mental health professional.

An evaluation should include a detailed inquiry into the history and nature of current symptoms and prior episodes and their management as well as any family history of depression and its treatment. From this information, the severity of current symptoms can be rated; this information serves as a baseline for measuring improvement over time and guides the course of treatment.

Once diagnosed, depression can be treated with psychotherapy, medication, or a combination of both. Medication may help reduce symptoms while psychotherapy addresses the negative thoughts, feelings, and beliefs that give rise to distress and that need to be managed in more productive ways.

Psychotherapies

For mild to moderate depression, psychotherapy is generally considered the best treatment option. Psychotherapy is important in helping patients develop strategies for dealing with the situations that give rise to depression and to effectively manage the negative thoughts and feelings that mark t he distress. Both cognitive-behavioral therapy (CBT), and interpersonal therapy (IPT) have been widely tested and shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT gives people skills to disarm negative styles of thinking and behaving. IPT helps people understand and work through troubled personal relationships that may cause or exacerbate their depression.

Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence. Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.

Medications

Antidepressants target various neurochemicals—notably serotonin, norepinephrine, and dopamine—known to be involved in the relay of signals through various brain circuits. Nevertheless, it is not entirely clear how they work or why they can take weeks or months to produce a positive effect—the brain is a highly complex organ.

The most popular medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft), among others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Now in use for decades, SSRIs and SNRIs coexist with older classes of antidepressants: tricyclics—named for their chemical structure—and monoamine oxidase inhibitors (MAOIs). The SSRIs and SNRIs tend to have fewer major side effects than the older drugs. However, medications affect everyone differently and there is no one-size-fits-all medication. Tricyclics and MAOIs remain important antidepressants. Finding a medication regimen that works for any particular patient may take trials of more than one antidepressant and more than one type of antidepressant.

Antidepressants typically take time to work. Patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect and continue taking the medication to maintain improved mood and to prevent a relapse of the depression. Although antidepressants are not habit-forming or addictive, abruptly ending an antidepressant treatment can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. The U.S. Food and Drug Administration requires a “black box” warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children, adolescents, and young adults taking antidepressants.

Side effects can limit the usefulness of SSRIs, SNRIs, tricyclics, and MAO inhibitors. People taking MAOIs must adhere to significant food and medicinal restrictions—from wine and cheese to decongestants— to avoid potentially serious interactions. Patients taking an MAO inhibitor should receive a complete list of prohibited foods, medicines, and substances at the time of prescription. The most common side effects of tricyclic antidepressants include dry mouth, constipation, difficulty emptying the bladder, sexual problems, blurred vision, dizziness, and daytime drowsiness. The most common side effects associated with SSRIs and SNRIs include headache, nausea, nervousness and insomnia, agitation, ands decreased libido.

The newest medication in the antidepressant arsenal is ketamine, an agent long used safely as an anesthetic. In randomized, controlled trials, a molecular variant of ketamine, called esketamine, has recently been found safe and effective as a treatment for depression. Administered by nasal spray, it acts very rapidly to improve mood. Further, studies show that it also reduces suicidal thinking. It is not fully clear how esketamine produces its antidepressant effects, but the drug has a mechanism of action that is different from any other available antidepressant drug. It binds to NMDA receptors in the brain, blocking uptake of the excitatory neurotransmitter glutamate, which causes a rapid increase in glutamate levels. The glutamate burst ultimately strengthens neural circuits in areas of the brain involved in motivation, memory, and mood, known to be impaired in depression. The new drug, trade-named Spravuto, is intended for adults with treatment-resistant depression and, because of its potential for abuse, is administered in doctors’ offices.

Herbal Therapy

Over the years, there has been considerable interest in the use of herbs for the treatment of both depression and anxiety. St. John’s wort (Hypericum perforatum), often used in Europe, has aroused interest in the United States as well, as it has been used for centuries in many folk and herbal remedies. A number of modern studies have tested the effectiveness of St. John’s wort for depression.

According to the National Center for Complementary and Integrative Health, “St. John’s wort isn’t consistently effective for depression. Do not use it to replace conventional care or to postpone seeing your health care provider.” Further, “St. John’s wort limits the effectiveness of many prescription medicines. Combining St. John’s wort and certain antidepressants can lead to a potentially life-threatening increase in your body’s levels of serotonin, a chemical produced by nerve cells.”

Neurostimulation Therapies

Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening, or for those who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required.

Lifestyle Changes

Research shows that a number of factors in daily living have a positive effect on mood states. These include a nutrient-rich diet, physical activity, exposure to sunlight and outdoors, and social activity. Lifestyle changes that address these factors are increasingly considered a wise course in any treatment plan.

How to Help Yourself If You Are Depressed

Depressive disorders can make a person feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make people feel like giving up. It is important to realize that such negative views are part of the disorder and typically do not reflect actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Even mild exercise, going to a movie or a ball game, or participating in religious, social, or other activities can help.
• Expect your mood to improve gradually; it takes time.
• Because depression distorts thinking, it is advisable to postpone important decisions until the depression lifts. Before deciding to make a significant transition—change jobs, get married or divorce—discuss it with others who know you well and have a more objective view of your situation.
• Let family and friends help you.

How Family and Friends Can Help a Depressed Person

The most important thing anyone can do for a depressed person is to help him or her get an appropriate diagnosis and treatment. It may require making an appointment on their behalf and accompanying them to the doctor. Encourage a loved one to stay in treatment is helpful.

Emotional support is also invaluable. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person’s therapist. Invite the depressed person for walks, outings, to the movies, and other activities. Keep trying. Although diversions and company are needed, too many demands may increase feelings of failure. Remind your friend or relative that with time and treatment, the depression will lift.

What Are the Signs of Depression?

Not everyone who is depressed experiences every symptom. Some people experience a few symptoms, some many. The severity of symptoms varies among individuals and over time.

Depression often involves persistent sad, anxious, or empty mood; feelings of hopelessness or pessimism; and feelings of guilt, worthlessness, or helplessness. It can also involve loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex. Decreased energy, fatigue, or a sense of being “slowed down” are also common, as are restlessness, irritability, and difficulty concentrating, remembering, or making decisions. Many with depression have thoughts of death or suicide.

People with depression may experience disruptions in sleep (insomnia, early morning awakening or oversleeping) and in eating behavior (appetite changes, weight loss or gain). Persistent physical symptoms may include headaches, digestive disorders, and chronic pain.

Signs and Symptoms of Depression

Everybody gets depressed sometimes, typically in response to events or experiences in which goals go unmet and expectations are dashed, but such reactions tend to be short-lived. Depression is regarded as a disorder when low mood and other symptoms persist for more than two weeks. Mood dysregulation revealed by unrelenting sadness may be the sign most associated with depression, but the disorder can be reflected in impaired functioning in almost every system of the body, from sexual desire to pain perception.

What are the major signs of depression?

Because depression is complex and affects so many systems of the body, it has many manifestations, and which ones are most prominent can vary from person to person. According to the latest edition of Diagnostic and Statistical Manual of Mental Disorders, widely used as a roadmap to diagnosis, depression can be considered an illness when at least five symptoms occur together for at least two weeks. Symptoms include:

• Feelings of sadness, emptiness, or hopelessness

• Irritability, angry outbursts, or low frustration tolerance

• Loss of interest in or ability to enjoy usual activities, from sex to sports

• Sleep disturbance, whether inability to sleep (insomnia) or sleeping too much (hypersomnia)

• Fatigue and lack of energy; everything feels effortful

• Appetite disturbance, including loss of interest in eating and weight loss or overeating and weight gain

• Anxiety, agitation, and restlessness

• Slowed thinking, moving, or talking

• Feelings of worthlessness and guilt, a focus on past failure, self-blame

• Difficulty concentrating, remembering things, and making decisions

• Recurring thoughts of death

• Physical pain such as headaches or back pain that has no clear cause.

I feel hopeless and empty. Am I depressed?

In many cases, yes. One of the hallmarks of depression is that it turns thinking relentlessly negative; it distorts cognition, which further depresses mood. Not only are experiences robbed of pleasure, your own thoughts tell you that you can’t do anything well and can’t change. People come to believe that they will always be this way, that situations will always end badly, and there is no way out of such a mental prison. But thoughts are not facts, and the distorted cognitions of depression are changeable through psychotherapy.

Why do I have no interest in sex?

No one is in the mood for sex all the time, but a persistently low sex drive is a common sign of depression in both men and women. Just as the disorder affects appetite for life in general and for food more specifically, it dampens the appetite for sex. Low libido is also influenced by the general lethargy and inability to feel pleasure that are hallmarks of depression; what’s more, it can both reflect and intensify relationship difficulties depressed people experience.

Can depression sometimes show up as agitation?

Although depression is most often associated with devitalization and typically shows up as a dampening of responsiveness and behavior, it can sometimes manifest as agitation and restlessness. In some studies, as many as one third of people with major depressive disorder had symptoms of agitation and physical restlessness. They may range from frequent wringing of the hands and shuffling of the feet to angry outbursts, as well as difficulty sitting still.

What does it mean to be clinically depressed?

The term depression is used in common conversation to cover a wide range of mood disruption, from momentary sadness to prolonged hopelessness. Clinical depression is a medical term that is reserved for the more serious forms of the disorder, also called major depression. People who are clinically depressed experience a number of symptoms In addition to unremitting sadness or disinterest—such as sleep problems and appetites disturbance—and their thinking is so relentlessly negative that their ability to carry out everyday functions is seriously impaired, and they cannot envision a brighter future.

How does depression differ from sadness?

Sadness is a normal response to disappointment, setbacks, and losses. Depression is not. Depression is accompanied by sadness, but it is distinguished by the presence of other symptoms as well. It descends like a pervasive cloud, often without any obvious trigger, robbing energy, motivation, meaning, and a sense of self-worth. It endures for weeks or months. Sadness turns people inward, encouraging them to find meaning or other accommodation, and then remits. Depression requires treatment; sadness does not.

How does depression differ from grief?

Grief is a normal response to loss of any kind, involving both sadness and longing for what is missing and, often, disinterest in one’s surroundings. And while acute grief, like depression, can interrupt appetite and sleep and create feelings of guilt, it is unlike depression in that it comes in waves, cresting and then subsiding. Typically, grief does not impair the capacity to remember happy experiences shared with the deceased or for laughter in recounting them. People who are depressed usually withdraw from social contact; the grieving often welcome contact.

How long do episodes last?

Depression is typically a recurrent disorder in which episodes of illness can last for weeks or many months. Researchers find that the median duration of a first episode of depression is 17.3 weeks, or about four months. There is a very high probability of recovery in the early weeks of a depressive episode. The severity of a first episode of depression —essentially the degree to which the body is functionally impaired, or in shutdown mode—seems to exert some influence on the likelihood of a recurrent episode.

What is the course of depression?

Depression is a recurring disorder, and about 50 percent of people who have one episode of depression have another. Studies show that the number of life stressors a person experiences influences the likelihood of recurrence. They also show that likelihood of recovery declines the longer that episodes last—a potent argument for seeking prompt treatment. There is some evidence that depression itself changes the brain, diminishing the ability to form new nerve cell connections and decreasing brain reserves, thereby curtailing the capacity for recovery.

At what age are people most likely to get depressed?

Depression is most likely to affect people in mid-life, between the ages of 45 and 65. Nevertheless, evidence indicates that people are experiencing an episode of clinical depression earlier in life than was previously the case. There is great concern that those in Generation Z (born between 1995 and 2015) are especially prone to depression and anxiety because they have been overprotected by parents and shielded from opportunities to develop skills for coping with life’s inevitable stresses.

Are people more prone to depression later in life?

Depression is not a normal part of aging; the disorder is less common among older adults than among younger adults, but is nevertheless a serious problem, as late-life depression is more often associated with suicide, self-neglect, and cognitive decline. When depression does occur among those over age 60, it is more likely than not to be a first episode. People with late-onset depression are less likely than others to have a family history of depression; there’s evidence that curtailment of daily activities is a significant precipitating factor.

Do children get depressed?

Children can get depressed, and research has documented clinical depression in children as young as age 3. The disorder tends to show up differently in children than in adolescents or adults. The most common symptom is extreme irritability. Other important signs are periods of social withdrawal, sadness or decreased ability to experience pleasure (anhedonia), and feelings of guilt. Depression in children may be a response to problems within the family, but it also may create problems in how a family functions. Some observers believe that the occurrence of depression in children is related to the decline of play.

What Causes Depression?

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biologic, environmental, and psychological factors. Major negative experiences—trauma, loss of a loved one, a difficult relationship, or any stressful situation that overwhelms the ability to cope—may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

Depression is not an inevitable consequence of negative life events, however. Research increasingly suggests that it is only when such events set in motion excessive rumination and negative thought patterns, especially about oneself, that mood enters a downward spiral.

Research utilizing brain-imaging technologies such as magnetic resonance imaging (MRI) shows that the brains of people who have depression look different than those of people who do not. Specifically, the parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. It is not clear which changes seen in the brain may be the cause of depression and which may be the effect.

Some types of depression tend to run in families, suggesting there may be some genetic vulnerability to the disorder.

Causes of Depression

As common as depression is—about one person in 10 experiences depression in any given year—it still eludes complete understanding. The trigger for depression can be almost any negative experience or hardship. Triggers can be external—losing a parent (especially when young), losing a job or developing a debilitating disease—or they can be internal and invisible, such a brooding over that most common of experiences, a failed relationship. People differ in their susceptibility, both by virtue of the biological heritage, their parenting heritage, their styles of thinking, the coping skills they acquire or deliberately cultivate, and the degree to which situations afford them the ability to control their fate.

What are the most common causes of depression?

Studies consistently show that depression is most associated with the number of stressors experienced in life, and the effect is cumulative—the more stresses that accrue over time, the greater the likelihood of getting depressed. The loss of an important relationship by death or divorce is experienced by most people as a major stress requiring significant adjustment.

Loneliness is both a physical and emotional stressor, and rates of loneliness, known to be high among the elderly, are sharply rising among the young, who increasingly report having no close friends. Job loss or the threat of job loss are almost invariably sources of constant worry. In the absence of a wide array of coping skills, even minor bumps on life’s journey can become significant stressors.

Does depression have some hidden trigger?

Although depression most often arises in response to some kind of defeat, depression can seem to arise out of the blue, for no obvious reason. It may even arise when life appears to be going extremely well. What is often hidden from conscious awareness are basic beliefs about life and love and work, or ways of explaining life’s twists and turns, many of which are learned at home in the early years of life.

Additionally, people may reach goals they’ve pursued for a long time, and find that they don’t deliver the emotional rewards they secretly or openly expected. In such cases, people may feel they don’t have the right to be depressed and may even feel ashamed of being depressed. Cognitive behavioral therapy is highly effective at unearthing and correcting such problematic views.

Can stress bring on depression?

Studies show that one factor consistently associated with depression is the number and degree of major stresses experienced in life. Poverty, for example, is a significant, enduring stressor, not easily modifiable, highly linked to depression risk. But to a degree still under study, attitude plays a major role in the perception of stress.

Some stress is necessary to keep people alert. It isn’t just that situations differ in the degree to which they stress human systems; much depends on how people regard some situations—say, taking final exams. People who see stress as a challenge rather than as a plague recruit positive rather than negative emotions. What’s more, they do not experience the harmful effects of stress hormones on body and brain.

How do thinking styles influence depression?

Brooding over mistakes or unpleasant experiences, jumping to catastrophic conclusions from one or two setbacks, overgeneralizing from limited evidence—all are errors of thinking, or cognitive distortions, strongly linked to depression.

Such thinking mires the brain in negativity and, if unchecked, breed self-doubt and hopelessness. What’s more, studies show that negative thinking styles such as catastrophizing actually change physiology. Researchers have found that they enhance reactivity to painful stimulation and raise levels of the stress hormone cortisol and of pro-inflammatory agents in the blood. The inflammatory response brings on behavioral changes commonly associated with both sickness and depression—fatigue, slow reaction time, cognitive sluggishness, and loss of appetite.

Do adverse experiences always result in depression?

Research documents that there is a strong relationship between adverse experience in childhood—such as verbal or physical abuse or household dysfunction caused by a mentally ill parent—and the lifetime risk of depression. Studies show that verbal abuse more than doubles the lifetime risk of depression. Adverse experiences are a significant source of stress.

But whether they summon resources for successful coping or lead to despair depends in part on the situation and in part on the person. A child facing verbally or physically abusive treatment at home or school who has no means of escaping continuing injury is at elevated risk for developing depression. Situations may not be subject to change—but attitudes, interpretation, and meaning of experience are always under individual control and can confer resistance to depression and other disorders..

How does perfectionism lead to depression?

Perfectionism is like an endless negative report card. Those in its grip don’t just hold high standards for themselves, they are perpetual self-critics, always judging themselves harshly. They focus on the very thing they most want to avoid—negative evaluation and failure. Perfectionism keeps people completely self-absorbed, always finding fault with themselves, a mindset that prevents them from taking on potentially-rewarding challenges.

Even when perfectionists complete a task, they cannot enjoy a sense of achievement; relentless concern with mistakes leads them to be haunted with uncertainty about their performance. The constant negative focus leads to a negatively distorted view of themselves, self-doubt, and feelings of inadequacy and worthlessness. Perfectionists are vulnerable to depression because their self-worth is contingent on fully achieving goals—a condition that, by definition, they can never meet.

How does learned helplessness contribute to depression?

Learned helplessness is a state of mind in which people come to believe (often through experiences of childhood abuse or neglect) that they have no way of escaping difficult or painful circumstances and therefore exert no effort to change distressing situations even when it is possible to do so. The resulting passivity can keep people from taking any measures to avoid a problem or to help themselves when one arises, or to seek help from others, compounding their own suffering and precipitating such feelings as hopelessness that are the hallmarks of depression. Because the helplessness is learned, the belief that no action matters can be unlearned; part of the cure is also gaining a realistic understanding of what can and can’t be controlled in life.

What is the role of inflammation in depression?

There is growing evidence that depression gives rise to inflammation and the inflammatory response creates or exacerbates depression. Neuroscientists know that there is lots of crosstalk in the brain between neural circuits and inflammatory pathways. Negative thoughts are a source of psychological pain.

Like all signs of injury, pain mobilizes various immune cells to help subdue the source, and that mobilization creates inflammation. Stress is known to activate an inflammatory response. The presence of inflammatory cells in the brain may be one reason many drug treatments for depression fail; they do not target inflammation.

How does loneliness lead to depression?

Loneliness assaults the body and mind in multiple ways. By itself, it is felt as a major stress, and is linked to the release of stress hormones, which are known to impair such brain operations as learning and memory retrieval. What’s more, loneliness magnifies the perception of all other stresses. It diminishes functioning of the immune system and readily leads to inflammation, a known pathway to depression.

The emotional discomfort of loneliness makes us feel sad, and sadness saps our energy and slows functioning of all body systems. Companionship is such a powerful buffer to all human difficulty that loneliness is said to have even more of a detrimental effect on health than cigarette smoking.

What happens in the brain with depression?

Many people believe that depression is caused by a “chemical imbalance” in the brain. Experts explain that depression is far more complex and that it is unproductive to think of depression as a brain disease that is primarily biological.

Instead, depression can be viewed as a behavioral shutdown in response to overwhelmingly negative situations in which you have little personal control, lack resources for dealing with them, and have little comfort in the way of social support. The response is reflected in many operations of the brain, such as difficulty with memory, sluggishness of thinking, inability to feel pleasure, loss of appetite and interest in sex, and heightened perception of pain.

Neuroimaging studies indeed show changes in brain function among depressed people, and they are generally associated with impairments of connectivity among brain areas that normally work together. Studies also show that such changes are reversible as depression lifts.

Are there risk factors for depression?

While genetics is believed to confer some susceptibility, there is no single gene or set of genes implicated; so far, it appears that a very large number of genes—likely modifiable by diet or behavior—each contributes a very tiny degree of vulnerability that could precipitate depression under conditions of stress. People can also be at risk of depression because of their personality attributes, particularly if they have a tendency to worry a lot, have low self-esteem, are perfectionists, are sensitive to personal criticism, or are self-critical and negative. Of the Big Five personality dimensions, the one most consistently associated with depression susceptibility is the trait of neuroticism. It denotes the degree to which the negative affect system is readily activated. People high in trait neuroticism are inclined to find experiences distressing, to worry, and to doubt themselves disproportionate to the circumstances they are in. In addition, studies indicate that women are at especially high risk for depression after divorce and men are at high risk following following financial, occupational, or legal problems.

If my mother or father was depressed will I be depressed?

Depression can be transmitted in families in several ways. Parents and children may share an array of genes that create susceptibility to depression. Even more subtly, parents may engage in depressive thinking and explanatory styles that children acquire unwittingly in the air they breathe every day at home while growing up.

There is considerable evidence that when mothers of young children are depressed, they fail to engage with their children. As a result, babies do not acquire the strong emotional bond that enables them to grow, to withstand stress, to develop emotional regulation, and to become responsive to others. Treating depressed mothers is often the best way to treat problems in children.

How is depression related to anxiety?

Depression and anxiety are considered two faces of the same coin. Both involve brooding over experience—in depression, things that happened in the past; in anxiety, things that might happen in the future. Depression is also thought to result from sustained anxiety. More than half of all people with major depression also suffer from persistent anxiety. The two conditions share many symptoms, including insomnia, difficulty concentrating, negative thinking, and loss of appetite. Many treatments that relieve depression also relieve anxiety.

Why are rates of depression rising?

Depression rates are rising especially among the young. While the lifetime risk of depression is approximately 20 percent, for the general population the highest rates currently occur among young adults, those between the ages of 18 and 29, while individuals over 65 have the lowest rates.

Experts cite several reasons why the young are especially susceptible. They range from social factors, such as decreasing availability of meaningful work, to individual factors, such as lack of coping skills due to overprotective parenting. Cultural factors figure in, too. An increased concern with safety and decreased tolerance for risk has curtailed the opportunities children have for free play, in which children experience joy, gain friends and learn social skills, and discover how to exercise control over their own life.

Are women more susceptible to depression than men?

Around the world, women are 1.7 times more likely to develop depression than are men, and the difference in susceptibility emerges in adolescence. Among younger women, the gender gap in depression is even greater, although before puberty, males and females have equal rates of depression. Studies pinpoint social and cultural reasons as well as biological ones.

Women more often experience internalizing symptoms, reflected in physical pain and other somatic complaints, social withdrawal, and self-blame, while men present with externalizing behaviors, reflected in irritability, anger, aggression, and substance use. In addition, childbirth is associated with a particular form of depression; susceptibility is thought to be related in part to the rapid hormonal shifts that occur postpartum in combination with the vastly increased demands of new motherhood.

How Is Depression Treated?

Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier treatment begins, the more effective it can be and the greater the likelihood that recurrence can be prevented.

Appropriate treatment for depression starts with an examination by a physician. Certain medications, as well as some medical conditions such as viral infections or a thyroid disorder, can cause the same symptoms as depression and should be ruled out. The doctor should ask about alcohol and drug use, and whether the patient has thoughts about death or suicide.

Once diagnosed, a person with depression can be treated a number of ways. The most common treatments are medication and psychotherapy. Many studies show that cognitive behavioral psychotherapy is highly effective, alone or in combination with drug therapy.

Psychotherapy addresses the thinking patterns that precipitate depression, and studies show that it prevents recurrence. Drug therapy is often helpful in relieving symptoms, such as severe anxiety, so that people can engage in meaningful psychotherapy.

Treatment of Depression

In the U.S. women are far more likely than men to seek treatment for depression—as with all other conditions. Nevertheless, it is extremely important for anyone suffering to take steps to treat depression to the point of remission—and several months beyond, which is the generally recognized standard of care.

While episodes of depression may eventually lift by themselves, that may take many months of physical and mental pain, sadness, and disinterest in life, and can be very costly to self, relationships, and work. There is considerable evidence that the longer a depression episode lasts, the more likely are future episodes of greater intensity.

That said, there are many effective treatments for depression, including psychotherapy, which aims to correct the errors of thought and belief that unwittingly underlie depression and to facilitate strategies for coping with stress; medication to provide relief of symptoms, including suicidal ideation, or to facilitate intensive psychotherapy; neuromodulation, involving methods of directly stimulating neural circuitry to restore effective communication between key areas of brain function. There are also many natural or lifestyle measures that individuals can take on their own, from diet and simple exercise to joining a chorus and practicing meditation.

Studies repeatedly show that psychotherapy is at least as effective as medication, and the most effective treatment for many people may be a combination of both.

Does depression ever go away on its own?

Depressive episodes may lift on their own, but even in the best-case scenario that can take many months and in the interim do significant damage to both your brain and your life. Experts believe that the inflammation involved in depression can, over time, contribute to neurodegeneration and, in a vicious cycle, accelerate pathologic changes in the brain that make future recovery more elusive. In one study of patients with major depression, 23 percent of untreated cases remitted within three months; 32 percent were in remission by six months, and 53 percent within a year. Remission is most likely among children and adolescents.

When does depression need treatment?

Any bout of depression that lasts more than two weeks can benefit from treatment, and the earlier it is begun, the better. Early treatment has the highest likelihood of bringing about full remission of symptoms and preventing relapse or recurrence. The so-called burden of depression is great, as the disorder is a major cause of missed work and poor productivity, and it has a devastating effect on relationships, family life, physical health, and general quality of life.

There are four main approaches to treatment—psychotherapy, antidepressant medications, neuromodulation, and lifestyle measures—and all address different facets of the disorder. Chronic and severe depression responds best to a combination of medication and cognitive behavioral therapy (CBT). Signs that depression is responding include less irritability, increased energy, feeling less overwhelmed, normalization of appetite, improved ability to concentrate, return of libido, and improved sense of self.

What is treatment-resistant depression?

When patients are given drugs, the effectiveness of the agents is evaluated at regular doctor visits by assessing symptom severity according to standardized criteria. Response is generally defined as a 50 percent reduction of symptoms. But response is not enough.

Even low-level symptoms can have deleterious effects on the brain itself, not simply increasing the likelihood of subsequent episodes but actually accelerating their occurrence. Depression is considered treatment-resistant after multiple types of medications, used singly and in various combinations, fail to significantly improve symptoms or create side effects that are intolerable.

What does psychotherapy do?

Drugs can relieve the symptoms of depression, but they do not cure depression. Major depression is caused by a number of factors, including ways of responding to stress and reacting to negative experiences and thoughts. Psychotherapy is aimed at the roots of depression, the ways people process their thoughts and feelings. Psychotherapy helps people understand the beliefs, feelings, and thoughts that contribute to their depression. It helps people identify the problems that trigger their depression or contribute to its continuation.

Therapy directs people to reestablishing sources of pleasure in life and helps them regain a sense of control. And it helps people develop effective coping strategies, important not only in relieving a current episode of depression but in preventing future ones. In cognitive behavioral therapy (CBT), the therapist actively helps patients identify and challenge negative thought patterns that contribute to their depressed mood.

The therapist also helps patients dissect what happens to them when they begin to feel emotionally overwhelmed by external events or their own thoughts, and jointly explores strategies—from meditation to reframing their thoughts—that help in such situations. Studies show that the benefits of CBT can be seen in 12 to 16 weeks of weekly sessions in a therapist’s office. CBT is especially good at preventing relapse of depression.

How do antidepressant drugs work?

In the brain, electrical signals speed messages from nerve cell to nerve cell but are relayed bychemical signals across the tiny gap between nerve cells. Antidepressant drugs affect those neurotransmitters, such as norepinephrine, serotonin, dopamine and others belonging to a class of chemicals known as monoamines.

Antidepressant medications such as the SSRI’s (selective serotonin reuptake inhibitors, the best known of which is Prozac) can increase or decrease neurotransmitters, act as substitute neurotransmitters, or regulate the receptors that the neurochemicals bind to. While those changes may contribute to the effects of antidepressant agents, they are not considered the main source of improvement. The reason is that those changes happen immediately, but the drugs can take six weeks or more to provide relief of symptoms. Researchers believe that the time lag is due to the development of new nerve cell connections—neuroplasticity—which pave the way for mental and behavioral flexibility.

Studies show that 40 to 60 percent of patients treated with an antidepressant experience an improvement in symptoms within six to eight weeks. Care standards specify that once remission is achieved, treatment should be continued for four to nine months.

When is ketamine used?

Ketamine, long used as an anesthetic, is now used against treatment-resistant depression in controlled circumstances. Infused intravenously in carefully titrated doses over a period of hours, it is very fast-acting, relieving symptoms within hours, with the effects of a single infusion lasting for days or a few weeks, in about 50 percent of patients. It is especially useful for helping patients troubled by suicidal ideation and is widely used in emergency psychiatry. A variant form of ketamine, esketamine, is delivered by nasal spray.

Ketamine works by blocking a non-monoamine neurotransmitter, glutamate, which influences the activity of all other neurotransmitters. It can have side effects, such as producing dissociation and hypertension, that, along with its short-lived effect, limit its use.

Do psychedelics help depression?

Given the large percentage of people for whom standard antidepressants do not work—more than 50 percent, in some studies—there is renewed scientific interest in psychedelic agents as treatments for depression, especially depression accompanied by suicide ideation. Ongoing clinical trials show that in carefully monitored settings, the substances, which broaden and deepen consciousness, can dramatically boost the effectiveness of psychotherapy for major depression, facilitating self-awareness and speeding behavior change. Psychedelic-assisted psychotherapy actually seems to motivate people to change, and brain imaging studies of treated patients show durable changes in brain connectivity patterns.

Strictly speaking, all drugs used to treat mental illness can rightfully be called mind-altering agents. But some classic psychedelics are already in clinical use. Ketamine is prescribed off label to treat depression. MDMA is in the advanced phase of clinical trials for treatment of post-traumatic stress disorder, often marked by severe depression. Exactly how agents like psilocybin work in treating depression is not clear, given their complex actions on the brain. They not only affect serotonin receptors implicated in depression; they also have powerful anti-inflammatory effects and stimulate neuroplasticity. As the therapeutic use of psychedelic drugs gains ground, interest has also grown outside the bounds of science in microdosing psychedelics— regularly taking small doses of such agents as a way to maintain mood and general mental health while avoiding the hallucinogenic effects.

What does brain stimulation, or neuromodulation, do?

In the evolving understanding of depression, the disorder is seen less as a neurochemical deficit, such as lack of the neurotransmitter serotonin or dopamine, than as a problem of wiring—a failure of activation of or interaction between key nodes in neural networks, or the very connections themselves, especially when processing emotion-related stimuli, reward stimuli, or executive functioning.

As a result, treatment now increasingly encompasses methods of electrically or magnetically altering nerve activity by selectively stimulating specific components of brain circuitry. Neuroimaging studies have repeatedly demonstrated functional abnormalities in networks linking such key areas of the brain as the hippocampus, amygdala, and prefrontal cortex.

The goal of neuromodulation is to stimulate neuroplasticity, to jump start the growth of new nerve connections to create new neural activity patterns that restore more mental and behavioral flexibility. Studies show that, over time, the devices can significantly improve mood and memory. Copycat devices are now being snapped up by elite athletes and others looking for a performance edge; they undergo a bout of stimulation before training.

Transcranial magnetic stimulation (TMS)

In transcranial magnetic stimulation (TMS), one or two externally placed electromagnetic coils deliver magnetic pulses to generate currents in deep brain tissue implicated in depression’s stall-out. The pulses generated are of the same type and, most often, of the same strength as those generated by magnetic resonance imaging (MRI) machines. No anesthesia is required, and stimulation is applied during a series of sessions in a doctor’s office. Approximately 60 percent of people who do not benefit from antidepressant medication improve significantly or achieve full remission with TMS treatment.

What are the major types of brain stimulation?

• In transcranial magnetic stimulation (TMS), one or two externally placed electromagnetic coils deliver magnetic pulses to generate currents in deep brain tissue implicated in depression’s stall-out. The pulses generated are of the same type and, most often, of the same strength as those generated by magnetic resonance imaging (MRI) machines. No anesthesia is required, and stimulation is applied during a series of sessions in a doctor’s office. Approximately 60 percent of people who do not benefit from antidepressant medication improve significantly or achieve full remission with TMS treatment.

• Transcranial direct current stimulation (tDCS) applies a weak electrical current to brain sites through the scalp from a headset-like device. The goal is to target brain circuits involved in attention, perception, learning, and memory that affect mood.

• In deep brain stimulation, reserved for highly treatment-resistant depression, an externally programmable device is implanted in the chest to deliver electrical signals to targeted sites in the brain. It is like a pacemaker for the brain.

• Intermittent theta-burst stimulation (iTBS) is a noninvasive form of brain stimulation approved for use in treatment-resistant depression.

How do I know which treatment is best for me?

There is a wide consensus among experts that mild depression responds to psychotherapy such as cognitive and behavioral therapy (CBT), without drugs. More severe depression responds best to a combination of drugs and psychotherapy. Antidepressant drugs are most effective against depression that is moderate to severe and chronic in nature.

Clinical psychiatrists who are highly experienced in treating depression have a general sense of which symptoms, and which clusters of symptoms, may respond to which antidepressant drugs. Still, more often than not, it takes a trial of one or more agents to find the most effective one, or combination of drugs, and the most effective dose, with the fewest, or most tolerable, side effects.

Sometimes side effects—nausea, weight gain, agitation, insomnia, loss of sex drive, difficulty reaching orgasm—are the deciding factors in whether to continue drug treatment. Treatment is successful when there is a complete remission of symptoms and patients can feel that they can function as well as, or better than, before they were sick.

Are brain scans useful in determining treatment?

Brain scans have been very helpful in research to identify brain regions that are key to processing emotional stimuli and circuits of neural communication altered in depression. This information has guided the development and use of various kinds of neuromodulation devices as treatment. It has also helped researchers assess the mode of action and effectiveness of drugs in development. It is also used in studies of the effectiveness of psychotherapy, to assess brain function before and after treatment.

But neuroimaging remains primarily a diagnostic and research tool, and a costly one at that. And while it is helping identify nerve circuits involved in distinct clusters of depressive symptoms, such use is very much for research purposes, In general, scanning does not yet provide enough specificity or utility for personalizing therapy.

Are there things I can do on my own to relieve depression?

Lifestyle changes can be extremely important in achieving depression relief. Chief among healthy habits to foster is addressing disturbed sleep, because sleep is so essential for feeling good and affects every system of body and brain. Establishing a regular sleep routine is considered essential, although sleep disturbance may be among the last symptoms of depression to completely resolve.

Stable sleep patterns by themselves have a positive influence on body metabolism and reduce the risk for cardiovascular disease that is associated with depression. Minimizing exposure to experiences of neglect and abuse is also important. Behavioral activation is a proven source of relief in depression, and while a therapist can help, patients can put it into action on their own.

Depression causes people to shut down; they lose interest in doing things, and their world contracts, depriving them of needed sources of stimulation and pleasure. Therefore, doing things—even when it goes against all instincts—brings about benefits on many levels. For example, maintaining social contact is a major source of relief; it acts physiologically, by tempering stress reactivity, and counters the bleakness of depression by providing a source of pleasure.

What’s the best way to help someone who has depression?

The very best way to help someone who is depressed is to get them to a therapist for treatment. There are many other ways to help. One is to silently pitch in on the chores of daily living that usually seem overwhelming to someone with depression.

Because depression can be thought of as behavioral shutdown, behavioral activation is important, even though the disorder destroys motivation. To support regular activity, better than reminding someone to get exercise is handing them a jacket and taking them out for a walk; the exercise, the sunlight, and the companionship all have antidepressant effects. So does the change of scenery. Establishing routines such as a regular sleep time is helpful. Also important is maintaining regular social contact with someone who is depressed.

What are the most effective natural treatments for depression?

Studies consistently show that an anti-inflammatory and metabolically functional diet, regular exercise, exposure to sunlight, social support and companionship, sleep, and sex have an effect on depressive symptoms. All are low-cost and noninvasive approaches to relief that require no prescription. All in fact contribute to general well-being of all people at all times.

In numerous scientific studies, a healthy diet that contains an array of anti-inflammatory compounds normally found in fruits, vegetables and fatty fish has been linked to lower rates of depression. In addition, studies show that depressed patients randomly assigned to a diet with reduced carbohydrates, sugar, and processed meats report fewer symptoms than those consuming a standard Western diet; remember, depression disrupts basic body metabolism.

Behavioral activation is a type of therapy that doesn’t have to be limited to therapists:It involves countering the effects of depression by encouraging patients to select and engage in rewarding activities that add necessary pleasure to life. Singing in a chorus is known to boost mental health; both the singing and the socialization affect autonomic nervous system reactivity to stress. Religious involvement is another proven stress buffer.

Why is exercise important?

Exercise is one of the most effective ways to jump-start neuroplasticity—the exit ramp from depression. Numerous studies show that engaging in simple activity such as walking immediately stimulates the growth of new nerve cell connections, the foundation of neuroplasticity.

Exercise appears to especially increase neuroplasticity in the hippocampus, a center of learning and memory and an area of the brain especially vulnerable to the disruptive effects of stress. In addition, weight training, or resistance, exercise has been shown to increase the signaling power of nerve cells.

How much physical activity is recommended to stave off depression?

Engaging in any form of exercise restores a sense of control over one’s life. Studies show that even 15 minutes of physical activity daily—especially in the afternoon—can have beneficial effects on mood, energy, and sleep. In a major study of nearly 34,000 adults, followed over 11 years, as little as one hour of physical activity per week was found to prevent 12 percent of expected future cases of depression.

Other studies show that exercise is an effective preventive measure even in those genetically predisposed to depression. Because depression dampens people’s motivation and energy, experts stress that it is important to start somewhere—doing anything is better than doing nothing— and to start small, beginning with a few minutes of walking.

Therapy for Depression

Good therapy is like driver’s education for the mind. It enables people to understand what sets off their descent into depression and not only helps them develop suitable tools for finding their way out but teaches ways of regulating difficult emotions going forward. Clinicians and researchers have long known that a prime contributor to depression is the inability to process negative emotions in constructive or adaptive ways. Medication can relieve some of the psychic pain of depression, but it does not help people learn good ways of coping with distressing experiences and feelings—which make them feel overwhelmed—or learn how to manage the kinds of thoughts that can trigger such feelings. As a result, they are always at the mercy of circumstances, ever-susceptible to depression. The goal of psychotherapy is to build the pillars of mental health.

Why is therapy important for treating depression?

From one perspective, depression can be seen as a state of depletion that occurs when problems overwhelm a person’s resources for solution. Therapy aims directly at the development of new solution patterns. It is at least as effective as medication during the period of treatment but its effects last longer and it is effective in preventing recurrence of depression. The coping techniques, problem-solving skills, and understanding of one’s own vulnerabilities gained during therapy are useful over the course of a lifetime.

Does therapy help in ways that medication does not?

Many studies have evaluate the effects of psychotherapy vs. medications. Medication for depression may relieve symptoms more quickly than therapy, but the symptom relief lasts only as long as medication is taken. Therapy has enduring effects; it not only relieves symptoms of a current episode of depression but reduces the risk of future episodes. Studies show that both types of treatment change the way the brain functions. Therapy gives people insight into how their own patterns of reactions to negative experience set off a downward spiral of thinking that lead to depression. It also fosters the development of coping skills that interrupt the chain of reactivity. Further, therapy restores a sense of control, something no medication can deliver. Perhaps most important, the bond that develops between patient and therapist becomes an instrument of support and recovery.

When is therapy used in conjunction with medication?

Because psychotherapy can take many weeks to months to have an effect, psychotherapy is frequently prescribed along with medication for people needing relief from severe depression, although less than a third of patients respond to the first drug they’re given. A new crop of medications for depression—all related to psychedelic drugs—appears to open new neural pathways to recovery and is proving especially powerful when used in conjunction with intensive psychotherapy. One such drug, ketamine, is fast-acting and has been shown to reduce suicidal ideation; administered intravenously, it is increasingly used for suicidal patients.

How is therapy coordinated with medication use?

Combination psychotherapy and pharmacotherapy (medication) for major depression is very common, both for acute and chronic forms of the disorder. Treatment with both modalities may begin simultaneously or be sequenced. Sometimes reduction in agitation or cloudiness of thinking or the abatement of psychic pain by medication is necessary before patients can be responsive to psychotherapy. Other times, medication can boost the effects of psychotherapy.

Typically, a psychiatrist or other medical doctor prescribes medication, monitors the response, and makes adjustments to the dosage or changes the type of medication as needed, while the psychotherapy is carried out separately by a psychologist or other mental health professional. Because the interaction between therapist and patient provides a prime window into a patient’s thoughts and feelings, the psychotherapist is also ideally positioned to observe the response to antidepressant drugs and deliver invaluable feedback to the prescribing physician. Patients do best when the two professionals are in regular contact coordinating their respective treatments rather than delivering them independently..

What does therapy do?

Therapy is just as “real” a treatment for depression as medication. It produces long-lasting changes in brain function that show up in brain imaging studies. It changes patters of connectivity between brain regions, enabling patients to exert more cognitive control over emotional reactivity.

Because major depression is a recurrent disorder, psychotherapy has the dual value of relieving current suffering and preventing future episode of distress. It also reverses the social and occupational decline depressed patients typically experience. Through a strong alliance with a therapist, in meetings, or sessions, typically held weekly for a limited period of time, patients learn to identify the kinds of inner and outer experiences that overwhelm them emotionally and set off the downward spiral of negative thinking and feeling that incapacitates them. Patients also learn to identify the distorted thinking patterns that contribute to hopelessness and despair. By discovering their own resources for problem solving, patients are equipped to regain control of their life.

How effectve is therapy?

Therapy is highly effective provided patients complete a prescribed course of therapy. Recent data show that only 10.6 percent of depressed patients haver ever received weekly therapy during their treatment period, which is typically 12 to 16 weeks. But when they do, therapy is more effective than medication over the long term and the effects are more enduring. Patients are less likely to need a second course of treatment and less likely to relapse. In fact, studies show that a single course of psychotherapy works at least as well as keeping patients on medication.

When is it best to seek therapy for depression?

After two weeks of persistent sadness or loss of capacity for pleasure, along with a sense of hopelessness or guilt and such physical changes as appetite shifts and early-morning awakening, it is wise to consider the possibility of major depression. Depression is diagnosed after a thorough health examination rules out treatable physical conditions, such as thyroid disorder, that can create many of the same symptoms. Therapy should be started as soon as a diagnosis of depression is rendered. The longer an episode of depression goes untreated, the more difficult it becomes to treat, the greater the possibility of future episodes, and the greater the possibility of inflammatory changes to the brain itself. Further, depression undermines functioning in every domain of life, including work and family; starting therapy soon minimizes the disruptive impact of the disorder.

Why is it important to seek therapy promptly?

Early treatment of depression is essential because depression itself changes the brain. Research shows that depression is linked to inflammatory changes in the brain. As a result of such changes, the longer an episode of depression lasts, the greater the likelihood of a recurrence of depression. Untreated, depression can become a progressive disease leading to neurodegeneration. Untreated depression especially compromises the prefrontal cortex, the area of the brain essential for reasoning and decision-making and enabling control of emotional reactivity. Therapy helps patients develop the skills not just to beat back a current episode of depression but to prevent future ones as well.

How soon will I notice any effect?

Research indicates that 50 percent of patients recover within 15 to 20 sessions, and many patients experience some improvement within a few sessions. Patients differ in the nature and severity of their problem and in their progress, but most patients experience a gradual return of ability to function. They also notice a lessening of hopelessness. The first sign that depression is improving may be a reduction in sadness or reduced pessimism about the future. There may be a lessening of irritability or a renewed interest in something once enjoyed. Feelings of guilt may also begin to abate.

How will know that therapy is working?

Feeling better is a good yardstick, but it is by no means the only measure of therapeutic effectiveness. Mental health professionals regularly assess the progress of therapy and rely on two important tools to monitor patient gains. One is their own experienced judgment of the patient’s ability to engage in the therapeutic process. The other is a standardized symptom rating scale that assesses patient standing on each of the constellation of symptoms of depression, from personal outlook to physical slowness. Has the veil on thinking or sluggishness of thought or speech persisted, lifted slightly, lifted significantly, or completely disappeared? Does the patient weep frequently, occasionally, or not at all? The most widely used symptom checklist is the Hamilton Rating Scale for Depression, often called the Ham-D.

How long will therapy be needed?

Research indicates that 50 percent of patients recover within 15 to 20 sessions. As with drug therapy, patients fare better when therapy is continued for a period beyond symptom remission. There are three goals of psychotherapy. The first is response—an improvement in symptoms. Patients may begin to experience improvement within a few sessions. The second is remission—disappearance of all symptoms and a return to healthy functioning in all domains of life. There may be a temptation to stop therapy at this point, but the consensus of experts is that treatment should continue at least four months after disappearance of symptoms to ensure recovery (the third goal of treatment) and to maintain the ability to handle the stresses of daily life that challenge coping skills. Completing a full course of therapy is critical for full recovery.

Can any type of therapy help?

For patients, recovery from depression requires understanding the kinds of events that precipitate a depressive response, awareness of their own psychological vulnerabilities, identifying distorted thinking patterns that lead to feelings of hopelessness, recognizing behavior patterns that exacerbate problems, developing problem-solving skills, and taking action even when they may not feel like it. An experienced therapist will gauge the best way to treat depression based on individual patient needs but incorporate all such goals into their treatment plan. However, there are several types of psychotherapy that specifically target one or more of these needs through treatment protocols that have been well-validated by extensive field-testing.

Are some types of therapy especially effective against depression?

Depression is a multifaceted disorder, and it responds to therapies that specifically target one or another area of dysfunction. Four types of therapy have proved effective in patients with depression extensively studied during treatment and followed up for significant periods of time afterwards. They are: Cognitive and Behavioral Therapy (CBT), Interpersonal Therapy (IPT), Psychodynamic Therapy, and Behavioral Activation (BA).

What does Cognitive Behavoral Therapy (CBT) do?

CBT takes straight aim at the distorted ways of thinking—often acquired early in life—that are typical of depressed people, and study upon study has proved its effectiveness. It is based on the evidence that negatively-biased thinking and beliefs give rise to the feelings of hopelessness and despair that are typical of depression, and changing thoughts changes emotions. Studies show that in depression, dysfunction in neural circuitry inclines patients to a negative view of themselves, the world, and their future, and therapy effectively alters patterns of neural transmission. CBT involves an active collaboration between patient and therapist that guides patients to challenge and test their own thoughts and beliefs, try out new behavioral strategies, and to curb reactivity to distressing situations.  

What does Interpersonal Therapy (IPT) do?

Like CBT, IPT is a short-term, present-oriented therapy. It’s primary target, however, is the difficultiy in interpersonal (social) functioning that both gives rise to and results from depression. Many studies support the value of ameliorating interpersonal distress as a route to relieving depression. IPT focuses on four major interpersonal problem areas—unresolved or complicated grief, struggles with a significant other (role disputes), role transitions such as the end of a marriage or becoming physically ill, and frank deficits in interpersonal skills. Patients learn to understand which problem area is linked to onset of their episode of depression and to directly redress those difficulties, often by learning how to better express their emotions. With supportive guidance from the therapist, they learn new communication strategies and may even rehearse through role play new solutions to longstanding social difficulties.

Is group therapy ever helpful?

Although depression is a very individualized disorder, with each patient exhibiting a distinctive patterns of symptoms, group therapy can sometimes be helpful. One area of special value may be group education in coping skills, problem-solving skills, and techniques for managing difficult emotions, as deficits in those areas are known to underlie most expressions of depression. Such treatment is often labeled psychoeducation and it may be especially appealing to people who cannot afford an individual course of therapy or who feel stigmatized by it. Whatever the format of depression group therapy, it can offer some advantages over individual therapy. Most obviously, it counters the social isolation that is a major precipitant of depression. Groups also allow for working though the dysfunctional relationship patterns that contribute to depression. Further, group interaction provides a forum for credible challenges to the negative evaluations depressed people make about themselves.

Can therapy help someone who is suicidal?

Studies show that about 5 percent of depressed patient have thoughts about suicide—suicidal ideation. Suicide is seen as a way of escaping the mental pain of depression, which distorts patterns of thinking and feeling so that sufferers cannot see a way out their current state of mind or envision a future possibility of feeling better.

Good therapy includes a specific assessment of suicide risk separate from the depression evaluation. It also includes specific measures to manage the risk of suicide in the present and the future. Many therapists draw up anti-suicide pacts with their patients. A contract may be written or verbal but, either way, patients at risk agree to commit no self-harm and to call the therapist if they ever have thoughts of ending their life, or to call an emergency number such as 911. In addition, studies show that such widely used treatments for depression as cognitive behavioral therapy (CBT) can be very helpful when adapted to specifically target the ways distorted thinking leads to depressive despair and thoughts of suicide.

How is progress evaluated in therapy?

While unstructured interactions with patients under their care can provide a window into patient functioning, therapists providing good care make regular assessments of a patient’s clinical status using criteria that have been validated in many studies. To know whether and how much depression is improving, they regularly monitor treatment progress by measuring the severity of multiple symptoms of depression on standardized scales. The most widely used assessment instrument is the Hamilton Rating Scale for Depression, or Ham-D, which gauges progress in 21 constellations of symptoms, from level of sadness to degree of guilty feelings to lack of energy to sleep problems. Severity is rated for each cluster of symptoms. Comparison of results over several sessions provides an accurate picture of treatment effectiveness and indicates areas where more intensive work may be needed.

Natural Approaches to Depression

Depression requires active treatment, because the disorder can have enduring effects on brain function that make future episodes more likely. The longer a depression episode lasts, the more likely a future episode.

However, there are many ways to treat depression, and some of the most effective, especially in cases of mild to moderate disorder, do not require a prescription or medical-type intervention of any kind.

Depression can be seen as a kind of cave, and it takes some time and effort to get out of the cave. But it is possible, usually by learning some new patterns of thinking and doing. Nutrition plays a role as well.

Natural Approaches to Depression

Depression requires active treatment, because the disorder itself can have enduring effects on brain function that make future episodes more likely. Apart from the intensity of emotional pain and despair, the longer a depression episode lasts, the more likely a future episode.

That said, there are many ways to treat depression, and some of the most effective, especially in cases of mild to moderate disorder, do not require a prescription or medical-type intervention of any kind. The irony of depression is that it saps mental energy and makes people feel uninterested in or incapable of doing anything, creating a state of avoidance.

Taking small, rewarding steps in spite of such feelings creates a pathway out of the problem. For example, just setting foot in a different location stimulates neural circuitry that leads to positive affect. Depression can be seen as a kind of cave, and it takes some time and effort to get out of the cave. But it is possible, usually by learning some new patterns of thinking and doing

Does depression always require drug treatment?

Although depression is in many ways a baffling and poorly understood disorder, there is growing recognition that it involves many body systems. That makes a powerful case for measures, most of them deceptively simple, that target one or more facets of depression. For example, depression is in part a disorder of social connection; the only remedy for that is social activity.

Studies consistently show that, by virtue of biology or early life experience, people differ in the degree to which distressing experiences can stress or overwhelm individual resources, disrupt functioning, and result in the system-wide shutdown know as depression. From learning to tolerate negative feelings to taking a walk in the park, there is an array of strategies that effectively interrupt or blunt the myriad effects of stress, and they can literally foster the growth of new nerve pathways that enable renewed interest in life and the ability to engage in it.

Why is a holistic approach helpful in treating depression?

Depression is a holistic disorder, a complex condition that afflicts the whole person, manifesting in many disturbances of mind and body function. It disrupts sleep as much as it impedes social interest. It fixates thinking on past failures as much as it keeps people from wanting to get out of bed. There is an array of measures that can counter the multiple ways depression disables so many systems of body and mind. Addressing cognitive distortions, disconnection from others, fatigue, a sense of purpose, a nutritious diet—and above all allowing the emotional time-out that depression demands—each addresses some facet of depression and all together provide an integrated way to restore health to the whole person.

Is there a natural way to target inflammation?

Inflammation plays a significant role in bringing on and perpetuating depression. Many studies show that depressed patients have higher levels of inflammatory compounds circulating in their blood. Inflammation is part of the body’s natural response to injury, and there are many ways of injury. So too are there many ways of curbing the processes of inflammation. Because one effect of stress is to increase inflammatory compounds in the body, finding effective ways of coping with stress—such as reframing difficulties as challenges or doing some exercise—lowers the body burden of inflammation.

Diet is another way to lessen inflammation. There are popular foods (such as fatty meats) that foster inflammatory processes, and there are common foods (such as strawberries) and nutrients (curcumin in the spice turmeric) that have anti-inflammatory properties, making healthy eating a sensible everyday approach to curbing inflammation.

How does exercise help depression?

Any exercise is activating and promotes a sense of accomplishment. Studies show that moderate-intensity aerobic exercise, such as walking for 20 to 40 minutes three times per week for six weeks, significantly alleviates many symptoms of depression, including self-concept, but is especially effective at relieving somatic symptoms, including sleep disturbance. What’s more, the benefits of exercise are long-lasting.

There are many explanations for the effects. Exercise raises core body temperature, which in turn crates feelings of relaxation and tension-relief. Exercise also promotes the release of endorphins, neurochemicals that have a direct mood-boosting effect. In addition, exercise counters depression by fostering a sense of self-efficacy. But the most enduring effect of exercise may be that it stimulates the release of nerve growth factors in the brain, leading to the growth of new nerve cells and new connections—literally opening new channels for thinking and acting.

What are the best exercises for curbing depression?

One of the most studied sources of depression relief is walking. Research consistently finds that walking for 20 to 40 minutes three times a week significantly improves mood and relieves other symptoms of the disorder. Walking alone has benefits, but walking with a partner or a group is even better, because the social interaction also lifts mood and adds to the motivation to continue the activity. Any activity that requires movement is beneficial, including stretching. Research shows that resistance exercise, such as lifting weights, is also effective against depression.

Are there vitamins or other supplements that help against depression?

The B vitamins —and especially folate (B9), pyridoxine (B6), and cobalamin (B12)—are crucial for nervous system function and play multiple roles in maintaining brain health. All the B vitamins are cofactors for enzymes involved in production of neurotransmitters that influence mood. Fish oil, rich in omega-3 fats, particularly the component fat eicosapentaenoic acid (EPA), curbs inflammations, enhances neuroplasticity, and protects brain cells against the degenerative effects of depression.

The spice turmeric contains curcumin, which has also been shown to improve symptoms in patients with depression. It not only has anti-inflammatory effects, it helps moderate the effects of the stress hormone cortisol. The mineral magnesium also reduces inflammatory substances in the body; additionally it stabilizes the levels of some neurotransmitters linked to depression.

Why are omega-3 fats important?

Found in fatty cold-water fish like salmon and mackerel, omega-3 polyunsaturated fatty acids contribute to general and brain health in a variety of ways. They maintain cardiovascular integrity and counter inflammation. They also play huge direct roles in brain function and are normally found in the brain in high concentrations; they make up the membrane of nerve cells and insulate the long arms so that nerve cells can efficiently relay signals.

Omega-3s also are neuroprotective, reversing the nerve cell degeneration that is an effect of depression. Studies show that omega-3 fats containing at least 60 percent eicosapentaenoic acid (EPA) are especially effective in relieving depression symptoms, likely because EPA has significant anti-inflammatory activity.

How can overall diet improve depression?

There’s no one specific diet that combats depression but there are a number of nutrient-rich foods that positively affect mental health and counter the effects of depression on the brain. Numerous studies link traditional Mediterranean-type and Japanese-style diets with low risk of depression. Both eating patterns involve lots of fruits and vegetables, fish more than meat, oils rather than solid fats, and moderate to minimal dairy consumption.

Most fruits and vegetables contain nutrients needed for brain health. In particular, studies show that berries—strawberries, blueberries, raspberries, blackberries, cranberries—with their high antioxidant content, contribute to brain efficiency and protect against neurodegeneration. Olive oil is another food that aids brain function. Fish, especially wild-caught, contain fats that help the brain. Whole grains, nuts and seeds, and low-fat dairy products similarly supply nutrients that boost brain health.

Are there foods it’s advisable to avoid in depression?

There are groups of food that have negative effects on metabolism and general body health, and virtually all of them are linked in one way or another to increased risk of depression or worsening of already existing depressive symptoms. Red and processed meats, for example, contribute to adiposity because they generally contain high amounts of fat, and especially saturated fat; adiposity raises the level of inflammation in the body, a contributor to depression risk. Sugars and refined grains impair glucose and insulin regulation, both important to brain energy. In addition, they contribute to inflammation and increase the production of free radicals of oxygen, which especially degrade brain cells.

How can sunlight help relieve depression?

The sun is not only the timekeeper of the universe but also of the human body, and all body functions are synchronized to a roughly 24-hour cycle set by patterns of light and dark. Even subtle disruptions of circadian rhythms, from sustained lack of sun exposure, dysregulate production of hormones such as melatonin and serotonin that affect nerve function and cognitive processes. Sunlight exposure resets the body clock, begets healthy blood flow in the brain, and triggers body production of vitamin D. Studies show that vitamin D plays important roles in maintaining brain health, stimulating the growth of nerve cells to preserve memory and executive function and sustaining mood..

Why is talk therapy good?

Talking about thoughts and feelings under the guidance of a trained therapist can help people gain control of their mental life and find a healthy perspective. Studies document that the patient-therapist relationship adds to the curative power of therapy. Specific types of talk therapy target the major ways the mind goes off-track in depression. Cognitive behavioral therapy (CBT), the best-studied therapy, is a structured treatment that helps people change the thinking styles and beliefs that limit them, mire them in negativity and guilt, lead to pessimism, and destroy their mental energy. Behavioral activation is a variation of CBT that helps people take baby steps of activity that bring pleasure, which in turn motivates continued activity, a growing sense of pleasure, and a renewed sense of self.

How does meditation work against depression?

Meditation provides a way of reducing negative reactivity to the stressful thoughts, feelings, and situations that are a major precipitant of depression. There are many styles of meditation, long a tradition in Eastern cultures, and meditation in some form has been incorporated into many behavioral therapies for depression.

Most forms of meditation are ways of recognizing the transience of thoughts and feelings, acknowledging them without giving them undue attention, and allowing them to pass without feeling the need to act on them. Mindfulness, a popular form of meditation that is often combined with CBT, teaches people to focus on the rhythm of their breathing while letting thoughts come and go. The goal is to detach people from their thoughts so that they can choose what to pay attention to, rather than be dragged down automatically by negative thoughts.

Does acupuncture work against depression?

Acupuncture involves the insertion of fine needles (or a laser beam) into specific points on the body. and the manipulation of those needles by hand or a small current of electricity to produce a therapeutic effect, such as relief of pain.

There is evidence that many of those points, particularly on the external ear, tap into branches of the autonomic nervous system (ANS), including the vagus nerve, and the manipulation of those points stimulates the ANS. One of the key functions of the ANS is regulation of the stress response, a major player in the onset and maintenance of major depression. The relatively small number of high-quality studies of acupuncture, as well as significant clinical experience, show that acupuncture reduces the severity of depression symptoms. Because he benefits tend to be short-lived, a series of treatment sessions is usually needed.

Why is social activity important?

Social activity is a natural buffer against depression. It breeds a sense of belonging and a sense of safety, both of which mitigate feelings of distress, promote a sense of well-being, and affect physiology to curb the output of stress hormones. Staying socially active also counters the effects of depression symptoms. It takes direct aim at the disconnection so many of the depressed feel.

One of the many consequences of depression is a heightened perception of —and reactivity to— social rejection. Feeling connected to others, whether to individuals or groups, boosts recovery in people with depressive symptoms, providing a particularly large dose of satisfaction and encouragement.

Depression and Your Health

Mental anguish is hard on your health: People suffering from depression have three times the risk of experiencing a cardiac event. In fact, depression affects the entire body. It weakens the immune system, increasing susceptibility to viral infections and, over time, possibly even some kinds of cancer—a strong argument for early treatment. It also interferes with sleep, adding to feelings of lethargy, compounding problems of focus and concentration, and generally undermining health.

Those suffering from depression also experience higher rates of diabetes and osteoporosis. Sometimes depression manifests as a persistent low mood, a condition known as dysthymia which is usually marked by years-long periods of low energy, low self-esteem, and little ability to experience pleasure.

Depression and Physical Health

Depression is widely thought of as a mood disorder based in the brain, but it is in fact a whole-body disorder. Lethargy, for example, is a common sign of depression that robs people of the will to move. But the links between depression and the body are more than just psychological. Depression has effects on body metabolism that limit available mental and physical energy. Depression negatively affects almost every system of the body. It disrupts sleep, affects appetite, alters the perception of pain, and weakens immunity—in addition to darkening your thinking and your outlook so that you can’t envision a brighter future ahead. Depression is so much a body disorder that experts believe that the vast majority of cases show up in doctors’ offices expressed primarily in physical symptoms such a chronic pain and fatigue.

Why does depression make me feel so listless?

For the vast majority of people with depression, fatigue is a prominent symptom, one of the first to appear and among the last to disappear with treatment. It makes people irritable, unable to concentrate, and generally disinterested in engaging in any activity. It also makes people slow and sluggish, and their energy is not restored by sleep.

The lack of energy is thought to be, at least in part, a response to inflammation. Many of the symptoms of depression are similar to the behaviors seen in many animals in the wild who have been infected by germs—they become less active, they withdraw from other animals, they become less responsive to pleasant-tasting substances. This cluster of responses is known as sickness behavior, and it is not triggered by the infectious agent but by the immune response set off by the threat of infection; it is spearheaded by cytokines, key signaling compounds of the immune system that set the stage for inflammation..

Does depression cause brain damage?

The longer an episode of depression lasts, the greater the likelihood of a recurrence of depression. That is because depression changes the brain in ways that are only now yielding to understanding. The sustained stress that triggers depression releases a cascade of hormones linked to shrinkage of the hippocampus, a part of the brain essential for storing and retrieving memories. Such an effect accounts for the memory problems those with depression typically experience.

It’s not clear whether treatment with current antidepressants always restores the size of the hippocampus. There are other cognitive changes due to untreated depression, such as a sustained bias to recalling negatively coded information, another hallmark of depression.

Untreated depression also changes the activity of substances that help regulate the mitochondria, the energy factories of all cells but which are especially critical to function of the brain because it is such a metabolically active organ. Through this mechanism and others, untreated or chronic depression can pave the way for the cognitive decline of dementia. Increasingly, depression is regarded as a neurodegenerative-like disease.

Can depression affect pain?

Statistics indicate that millions of Americans suffer from chronic pain—as well as 20 percent of people worldwide—especially low back pain. Chronic pain is a significant stress on the body that can itself induce depression. Studies show that depression also causes changes in the network of brain areas involved in processing physical pain, including the cortex and lower-brain centers. The pain network appears to be hyperactive in depression, and the degree of activity that can be seen in such areas on brain scans correlates with the severity of depression that patients experience.

Researchers also find that when antidepressants have an effect on depression, it is at least in part by reducing the activity of the pain pathways. What doctors haven’t figured out yet is why heightened pain is experienced so differently among patients, with some experiencing pain as mental anguish and other having somatic complaints of physical pain.

What role does the immune system play in depression?

The immune system is now thought to be a significant factor in depression, as scientists recognize the many channels of communication between the immune system and the nervous system. There’s mounting evidence that depression can be caused by inflammation anywhere in the body. One of the many effects of stress, which is so often a precipitant of depression, is to raise levels of cytokines in the body.

Cytokines are one type of immune signaling substances that are released when there is a danger to cells, such as the possibility of infection. They stimulate inflammation as a way to make the cellular environment hostile to invaders. Researchers have long known that levels of inflammatory agents are elevated in patients with depression. They now know that such pro-inflammatory agents can penetrate the so-called blood-brain barrier and change the way the brain functions. They induce many of the behaviors characteristic of depression—reducing energy and activity, minimizing social contact, diminishing pleasurable sensations. There’s some evidence that they also weaken the neural connections between parts of the brain essential for processing emotional stimuli.

How does depression affect body weight?

Depression has profound effects on body metabolism. The elevated levels of the stress hormones associated with depression have, among their many effects, a direct impact on glucose metabolism in the body. The net effect is an increase in insulin resistance, which leads to the accumulation of belly fat. Depression not only raises the risk of diabetes but, independently, of weight gain. In addition, depression especially impairs the motivation to do anything, so those with depression get little exercise, another contributor to weight gain. The gain of belly fat is another way by which depression also makes sufferers prone to heart disease.

What role does the heart play in depression?

Heart disease has long been associated with major depression, both as cause and effect. Feelings of depression are common after a heart attack. Nevertheless, depression is an independent risk factor for cardiac disease. Clinicians and researchers identify several biological pathways by which depression may precipitate a cardiac event. People with depression have elevated levels of inflammatory substances that are known to play a direct role in heart disease.

They also have alterations in blood platelets, cells in the blood that are essential to the clotting mechanism. Another possible link between depression and heart disease is dysregulation of the autonomic nervous system (ANS). The altered stress reactivity common in depression also disrupts the ANS, which controls many aspects of heart function; one effect is an increased likelihood of cardiac arrhythmias.

The stress-related hormones that have detrimental effects on brain function put a burden on cardiac function in other ways—such as by altering glucose metabolism in energy-hungry heart cells. A recent study of nearly 150,000 people in 21 countries reports that cardiovascular events and death increased by 20 percent in people with four or more depressive symptoms compared to people without. The risk increased in all countries but was more than twice as high in urban than rural areas and twice as high in men than in women.

Living with Depression

Everyone experiences an occasional blue mood. Yet clinical depression is a more pervasive experience of repetitive negative rumination, bleak outlook, and lack of energy. It is not a sign of personal weakness or a condition that can be willed or wished away. People with depression cannot merely “pull themselves together” to get better.

It doesn’t help that modern-day living carries growing pressures. There is an emphasis on early childhood achievement at the expense of free play, a cultural shift away from direct social contact in favor of electronic connection, and a focus on material wealth at the expense of rich experiences and social contact. All play a part.

However, there is some evidence that, painful as depression is, it may serve a positive purpose, bringing with it ways of thinking that force those who suffer to focus on problems as a prelude to solving them. In effect, some researchers hypothesize that depression can help prod a person into much needed self-awareness.

How to Prevent and Manage Depression

No one is immune to depression. It can occur in those who are susceptible by virtue of family history or biology; chronic poverty, disease, or deprivation; or childhood experience that resets reactivity of the nervous system so that it overresponds to stress. It can settle in after a series of upsets or losses. But it can also catch people off guard.

Maintaining mental health is a task everyone faces. Just as most people have learned that it takes some work to stay in physical shape, so does mental health require some attention and upkeep. Most of us live fast lives in which insults and injuries accrue that need to be redressed. We may have a clever array of defenses that keep us from knowing what is roiling us below the surface—until it saps all our mental and even physical energy and starts to shut down our ability to function. As with physical health, maintaining mental health and building resilience may be more of a challenge for some than for others. But there are many measures that anyone can take to avoid or even reverse the shutdown cycle that depression imposes.

Can depression be prevented?

Studies consistently show that episodes of depression can be prevented even among people who have already suffered at least one episode of the disorder. Many factors contribute to bringing on a bout of depression, and it takes attention to many elements to depression-proof yourself.. There are lifestyle factors, such as diet and exercise, that play important biologic roles. Styles of emotion management and expression can contribute to susceptibility to depression or protect against it. Relationships carry great weight in mental life, and creating healthy relationships is one bulwark against depression. There are patterns of thinking and sets of beliefs that can pave the way for depression, and changing them—an aim of Cognitive and Behavioral Therapy (CBT)—can put a brake on depression. Having meaningful goals in life is a powerful antidepressant, and taking practical steps towards them is an evidence-based way of not only preventing but reversing depression.

Depression runs in my family—can I avoid it?

A family history of depression raises the risk of the disorder, but it does not make it inevitable or even likely. There are many steps that can be taken to minimize the risk or avoid depression. In most cases it isn’t clear exactly what it is that’s transmitted in a family that creates susceptibility. Yes, there may be patterns of genes that lower the threshold for disorder, but families also tend to transmit to their children many mental habits that later influence susceptibility to difficulty. For example, the adults may have pessimistic thinking styles and fatalistic beliefs that get transmitted with every explanation they provide; they may have a positive or negative orientation to the future, or they may have difficulty mounting an effective approach to problem-solving. So too, there might be habits of handling emotions, especially negative feelings, that could pose problems later on in life, especially in the face of difficult experiences. Of the many traits that families pass on, many can be examined and modified as needed.

What risk factors for depression can I control?

There are situations and experiences that raise a person’s risk of depression. Chief among them are abusive or chronically conflicted relationships, loss of a relationship or job or anything of significance, and major setbacks or disappointments in any realm of life. While the death of a spouse or the loss of a job may not be under anyone’s control, such situations can be met with the recognition that extra self-protective measures are needed—a heavy dose of self-care, including adequate sleep and exercise; extra emotional support from others; even help with the chores of daily living. Relationships are almost always open to improvement, and professional counseling can be very helpful.

There are also individual traits that create risk for depression. Chief among them are patterns of negative thinking and coping with emotions, particularly in response to difficult experiences. All of them can be changed, with attention and practice, and doing so is one of the main goals of Cognitive and Behavioral Therapy. While it may not be possible to change the amount of stress one is regularly subjected to, it is not only possible but desirable to change ways of perceiving and handling stress. Meditation has become a highly popular practice in Western countries for a reason—it is an effective way of lessening reactivity to stress.

What kinds of situations carry a special risk of depression?

Experiences of abuse, neglect, and loss can set the stage for depression, as can personal setbacks and disappointments, such as failure to achieve one’s goals. Any high-stress situation—conflict with the boss, financial problems—can lead to depression if it lasts for a long enough period of time, creates feelings of helplessness, and overwhelms the ability to cognitively and emotionally digest the experience. Because humans are fundamentally social creatures, relationship difficulties, social rejection, and divorce, even when it provides relief from conflict, can precipitate depression. Isolation and loneliness are major risk factors, and while they respect no age or stage of life, are special problems among the elderly. Any chronic illness carries a higher-than-normal risk of depression, and so does sudden life-threatening illness, such as a heart attack or cancer diagnosis. Any of them—or even the memory of them—can trigger the downward spiral of negativity, hopelessness, and immobility that typify depression, but depression is never inevitable in any situation.

Can changing how I handle stress spare me from depression?

Changing ways of handling stress can go a long way to minimizing the risk of depression. In relatively brief bursts, stress is good, fostering alertness, learning, and adaptation. Severe or prolonged stress, however, dysregulates the normal stress response and impairs memory, learning, and general brain functioning; depression is consistently associated with the number of stressors experienced in life. Because some stress is inevitable and not within human power to prevent, maintaining mental health requires a wide array of coping skills, from the ability to articulate feelings to the ability to stay focused.

In addition, it’s possible to cut stress off even before coping skills must be deployed. Attitude plays a major role in the perception of stress. People who see stress as a challenge rather than as a curse recruit positive rather than negative emotions and do not experience the harmful effects of stress hormones on body and brain. Further, learning any of various forms of meditation can enable people to interrupt the automatic response patterns to stress that prove so harmful. Changing perception of stress, curbing reactivity to it by meditation, acquiring an arsenal of coping skills—all are ways of lessening the burden of stress and protecting against depression.

How can I stop myself once I start slipping into negative thinking?

It is possible to choose your thoughts, and the most effective treatment for depression, Cognitive and Behavioral Therapy, is based on that proven possibility. It itemizes the kinds of self-defeating and negative thoughts that appear to be almost automatic in the wake of stress or setback and offers a number of techniques for refuting and rechanneling them. There are many kinds of negative thoughts that destroy mental energy, from all-or-nothing thinking to discounting positives to catastrophizing. For example, after getting turned down for a job you tried hard for, you might get into a funk by concluding ”I’ll never get a job.” But that is an illogical conclusion from one piece of evidence and hardly the only possible outcome. Learning how to stop negative thinking does not require therapy, but therapy offers a well-tuned systematic approach, the opportunity to catch thinking errors, and support for correcting them.

Can meditation help ward off depression?

Studies show that one factor consistently associated with depression is the number and degree of major stresses experienced in life. Meditation provides a way of reducing reactivity to the stressful thoughts, feelings, and situations that are a major precipitant of depression. There are many styles of meditation, and meditation has been incorporated into many behavioral therapies for depression. Meditation slows down reaction so that it is not automatic, and it trains people to recognize that, however troubling thoughts and feelings are in the moment, they are not facts, they are transient, and they can be acknowledged without needing to be acted upon. Mindfulness is a popular form of meditation that teaches people to focus on the rhythm of their breathing while letting thoughts and feelings come and go. The goal is to detach people from their thoughts so that they can choose what to pay attention to, rather than automatically buying the negative thoughts of depression and being dragged down by them.

Are there foods that help fight off depression?

Increasingly, diet is recognized as an important influence on susceptibility to depression, and a recent study shows that an overall healthy diet works against even severe depression. Essentially, any diet that’s good for the heart is also good for the brain, providing a number of nutrients that play key roles in the operations of the nervous system. Numerous studies link traditional Mediterranean-type and Japanese-style diets with low risk of depression. Both eating patterns involve lots of fruits and vegetables, fish more than meat, oils rather than solid fats, and moderate to minimal dairy consumption.

In addition to a generally heathy diet, specific nutrients have been shown to confer depression resistance. Omega-3 fatty acids, found in wild-caught fatty fish such as salmon, maintain cardiovascular integrity and combat inflammation. Normally found in the brain in high concentrations, they make up the membrane of nerve cells and facilitate efficient transmission of nerve signals. They also reverse the nerve cell degeneration that is an effect of depression. Colorful vegetables provide antioxidants, which are especially needed by brain cells and also counter inflammation. Vegetables are also good sources of B vitamins, which play multiple roles in maintaining brain health and, as cofactors for enzymes involved in production of neurotransmitters, directly influence mood. Studies show that berries, with their high antioxidant content, contribute to brain efficiency and protect against neurodegeneration. Olive oil is another food that aids brain function.

Are there actions I can take to ward off depresssion?

Exercise is one of the most effective antidotes to depression. Engaging in simple activity such as walking immediately stimulates the growth of new nerve cell connections—the exit ramp from depression. In addition, engaging in any form of exercise restores a sense of control over one’s life. Studies show that even 15 minutes of physical activity daily can have beneficial effects on mood, energy, and sleep, and it works even in those genetically predisposed to depression. Because depression robs people of motivation and energy, it is important to start somewhere—doing anything is better than doing nothing— and to start small, beginning with a few minutes of walking. Establishing a regular sleep routine helps, as sleep normalizes many body functions disrupted by depression. Depression causes people to shut down; they lose interest in doing things and their world contracts, robbing them of needed sources of stimulation and pleasure. Therefore, doing things, including maintaining social contact—even when it goes against all instincts—brings about benefits on many levels. Sunlight is another antidepressant, and adequate sunlight exposure helps sustain mood.

Are there common triggers of depression that I can control?

While stress is a common trigger for depression, exactly what people find stressful can be highly individualistic, as is the capacity to tolerate stress. Stress tolerance is to a large degree under personal control, and the ability to withstand stress can be deliberately cultivated—from knowing how to summon resources such as social support to accessing problem-solving skills. It is also possible to down-regulate another significant trip-switch for depression—negative reactivity to negative experiences, whether romantic rejection or job loss. Such experiences may not be avoidable in life, but the downwardly spiraling patterns of negative thinking they typically set in motion, while they feel automatic and inevitable, can in fact be interrupted and countered, once awareness is drawn to them.

Is it possible to head off full-blown depression once my mood slips?

Depression often starts surreptitiously—a disturbance in sleep patterns, feelings of apathy or irritability, withdrawal from friends—and because these shifts all tend to worsen mood, it is the nature of the beast to beget a downward spiral of thinking and feeling and reacting until hopelessness and immobility are all-consuming. It’s possible to intervene but only by becoming aware of the early signals. Then it’s important to quickly engage some countermeasures—which often means fighting the powerful desire to do as little as possible. That is one of the paradoxes of depression: It pulls you away from the very things that will actually make you better. Here’s where reaching out to a support network can be critical. And forcing yourself to take a 10-minute walk. If you find your mood cratering often enough, you might want to make a list of things to do when that happens and stick it on the refrigerator door, or slip it into your sock drawer for ready access when you need it.

How can I prevent a relapse of depression?

Without exception, one of the goals of treating depression is to prevent future episodes, and that is why Cognitive and Behavioral Therapy is so effective, even for those at high risk of relapse: It teaches ways of stopping the negative thought patterns that feed on themselves to drag people down into depression. The more episodes of depression a person has, the more that negative patterns of thinking take on a life of their own and become automatic. Significantly, the same techniques that therapists teach are available for anyone to deploy—the trick is being able to step out of the thoughts as they’re occurring, becoming aware of them and their oppressive effects, and then opposing them. Studies consistently show that stopping negative rumination is one of the most powerful tools for relapse prevention. So is taking steps to resolve situations that can engender despair, such as chronically conflicted relationships.

The Major Forms of Depression

What most people mean when they talk about depression is unipolar depression—an unremitting state of sadness, apathy, hopelessness, and loss of energy. It is also called major depression.

Depressive episodes also occur in bipolar disorder, a condition marked by periods of depression interspersed with periods of high-energy mania. People swing between the two poles of mood states, sometimes over the course of days, and sometimes over years, often with stable periods in between.

The birth of a baby can trigger mood swings or crying spells in the days or weeks that follow, the so-called baby blues. When the reaction is more severe and prolonged, it is considered postpartum depression, a condition requiring treatment because it can interfere with a parent’s ability to care for their newborn.

Depression can also occur seasonally, primarily in the winter months when sunlight is in short supply. Known as seasonal affective disorder, or SAD, it is often ameliorated by daily exposure to specific types of artificial light.

Types of Depression

Depressed mood is a significant feature of other mental health conditions besides major depression. Many experts recognize four major types of depression: major depressive disorder, the depression of bipolar disorder, postpartum depression, and a low-grade, chronic depression known as dysthymia. Because of the array of symptoms, their timing, the multiplicity of causes, and the involvement of other body systems in depression, there are many lenses through which clinicians and researchers look at, classify, and treat the disorder.

Some experts believe that the clearest way of understanding depression is through its effects on metabolism—essentially whether it causes weight gain or loss, either way involving fundamental changes in the way body cells utilize glucose, the brain’s primary energy source. How depression is understood and classified is not just a matter of academic interest—it influences the approach to treatment and especially the search for new therapies for this often-treatment-resistant disorder.

What causes postpartum depression?

Postpartum depression, also known as postpartum disorder, is a form of major depression set off by the dramatic hormonal changes women experience in the weeks and months after childbirth, coinciding with the many lifestyle changes and demands that usually accompany new motherhood.

However, research shows that, 50 percent of the time, the mood shifts and anxiety that characterize postpartum depression actually begin during pregnancy; for that reason the condition is also sometimes called peripartum depression. Of the 3 to 6 percent of women who develop postpartum depression, a small number experience psychotic symptoms, such as command hallucinations ordering them to kill the baby. By contrast, up to 80 percent of women develop a relatively mild form of mood shifts after childbirth, the so-called baby blues, and the symptoms usually lift in weeks.

When is depression a sign of bipolar disorder?

Bipolar disorder is marked by episodes of depression punctuated with episodes of mania, during which people feel euphoric and display intense excitement, frenetic activity, grandiosity, and, often, delusions. The condition bears features of both depression and schizophrenic disorders. And while the lows of depression are its most pervasive expression, it is the high of mania that seals the diagnosis of bipolar disorder, sometimes called manic depression.

What triggers the mood switch is usually not clear, but changes in circadian rhythms, whether internally induced by lack of sleep or externally imposed by changes in daylight exposure, is known to play an important role. The condition, although relatively common—it affects 2.6 percent of the U.S. population—is frequently misdiagnosed, especially in children.

What is seasonal affective disorder?

Seasonal affective disorder, or SAD, is a type of recurring major depression kicked off by seasonal change—usually starting as days get darker and shorter in the fall and relenting in the spring. In a small number of people, the seasonal effect is the opposite: They experience the typical signs of depression during the spring or early summer with the extended period of daylight. Lethargy and oversleeping, or hypersomnia, are common features of winter SAD, along with weight gain; summer SAD is more often accompanied by insomnia, marked by the inability to fall or stay sleep. SAD is four times more common among women than among men and is far more common in northern states than in southern ones. Shortage of daylight, inability to produce vitamin D from sun exposure, and overproduction of the hormone melatonin (kicked off by the onset of darkness) are all implicated in SAD.

Does depression occur with PTSD?

Approximately half of people with posttraumatic stress disorder also suffer from major depressive disorder. The two conditions share a number of symptoms, from depressed mood and sleep disturbance to concentration difficulties and feelings of guilt. But some experts now believe that the co-occurrence of major depression with PTSD reflects a distinct subtype of PTSD, as those with both conditions experience significantly impaired cognitive functioning, significantly impaired daily functioning, and are at greater risk for suicide than those with PTSD alone.

Evidence suggests that those most at risk for both PTSD and major depression have a history of childhood maltreatment, especially physical abuse. Neuroimaging studies indicate they may also have fewer nerve connections in brain circuits that process emotional memories.

What other disorders are linked to depression?

Dysthymia, officially known as persistent depressive disorder, is a low-grade depression that lasts for periods of two years or more and recurs over the lifetime. It is less severe than major depression, but more chronic. Dysthymia may not prevent people from functioning day to day, but it robs them of feelings of enjoyment and pleasure, causes sluggishness and lethargy, and often results in weight gain. Depression is also commonly an accompaniment to cardiac disease, and there is evidence that it can both cause or exacerbate heart disease and result from it.

Depression can also occur in response to almost any other chronic ailment, because chronic illness usually forces twin challenges on people—to make adaptations to their self-concept and to make significant lifestyle adjustments that may curtail participation in once-enjoyable activities.