NIH Publication No. 03-4972 

Printed 2003; Reprinted June 2003 

Table of Contents 

Depression

Types of Depression

Symptoms of Depression and Mania

Co-Occurrence of Depression with Other Illnesses

Causes of Depression

Men and Depression

Depression in Elderly Men

Depression in Boys and Adolescent Males

Suicide

Diagnostic Evaluation and Treatment

 · Medications

 · Side Effects

 · Psychotherapies

 · Herbal Therapy

How to Help Yourself if You Are Depressed

How Family and Friends Can Help

Where to Get Help

Conclusion

For More Information

References

 

1 
2 
 

 

elf-concept, and the way one thinks about things. A 

mood.

or

ost

s

depressive disorder is not the same as a passing blue

It is not a sign of personal weakness or a condition that can 

be willed or wished away. People with a depressive illness 

cannot merely "pull themselves together" and get better. 

Without treatment, symptoms can last for weeks, months,

years. Appropriate treatment, however, often involving 

medication and/or short-term psychotherapy, can help m

people who suffer from depression.

3 
"I can remember it started with a loss of interest in 

basically everything that I like doing. I just didn't feel like 

doing anything. I just felt like giving up. Sometimes I 

didn't even want to get out of bed."

 -Rene Ruballo, Police Officer 

Depression can strike anyone regardless of age, ethnic 

background, socioeconomic status, or gender; however, 

large-scale research studies have found that depression is 

about twice as common in women as in men.1,2

 In the United 

States, researchers estimate that in any given one-year 

period, depressive illnesses affect 12 percent of women 

(more than 12 million women) and nearly seven percent of 

men (more than six million men).3

 But important questions 

remain to be answered about the causes underlying this 

gender difference. For example, is depression truly less 

common among men, or are men just less likely than women 

to recognize, acknowledge, and seek help for depression? 

In focus groups conducted by the National Institute of 

Mental Health (NIMH) to assess depression awareness, men 

described their own symptoms of depression without 

realizing that they were depressed. Notably, many were 

unaware that "physical" symptoms, such as headaches, 

digestive disorders, and chronic pain, can be associated with 

depression. In addition, they expressed concern about 

seeing a mental health professional or going to a mental 

health clinic, thinking that people would find out and that this 

might have a negative impact on their job security, promotion 

potential, or health insurance benefits. They feared that 

being labeled with a diagnosis of mental illness would cost 

them the respect of their family and friends, or their standing 

in the community. 

Over the past 20 years, biomedical research including 

genetics and neuroimaging has helped to shed light on 

depression and other mental disorders—increasing our 

understanding of the brain, how its biochemistry can go awry, 

and how to alleviate the suffering that mental illnesses can 

cause. Brain imaging technologies are now allowing 

4 
scientists to see how effective treatment with medication or 

psychotherapy is reflected in changes in brain activity.4 As 

research continues to reveal that depressive disorders are 

real and treatable, and are no more a sign of weakness than

cancer or any other serious illness, more and more men with 

depression may feel empowered to seek treatment and find 

improved quality of life. 

Types of Depression 

Depression comes in different forms, just as is the case with 

other illnesses such as heart disease. This booklet briefly 

describes three of the most common types of depressive 

disorders. However, within these types there are variations in 

the number of symptoms, their severity, and persistence.

Major depression (or major depressive disorder) is 

manifested by a combination of symptoms (see symptom list 

below) that interferes with the ability to work, study, sleep, 

eat, and enjoy once pleasurable activities. A major 

depressive episode may occur only once; but more 

commonly, several episodes may occur in a lifetime. Chronic 

major depression may require a person to continue treatment 

indefinitely. 

A less severe type of depression, dysthymia (or 

dysthymic disorder), involves long-lasting symptoms that do 

not seriously disable, but keep one from functioning well or 

feeling good. Many people with dysthymia also experience 

major depressive episodes at some time in their lives. 

Another type of depressive illness is bipolar disorder

(or manic-depressive illness). Bipolar disorder is 

characterized by cycling mood changes: severe highs 

(mania) and lows (depression), often with periods of normal 

mood in between. Sometimes the mood switches are 

dramatic and rapid, but usually they are gradual. When in the 

depressed cycle, an individual can have any or all of the 

symptoms of depression. When in the manic cycle, the 

individual may be overactive, over-talkative, and have a great 

deal of energy. Mania often affects thinking, judgment, and 

5 
social behavior in ways that cause serious problems and 

embarrassment. For example, the individual in a manic 

phase may feel elated, full of grand schemes that might 

range from unwise business decisions to romantic sprees 

and unsafe sex. Mania, left untreated, may worsen to a 

psychotic state. 

Symptoms of Depression and 

Mania 

Not everyone who is depressed or manic experiences every 

symptom. Some people experience a few symptoms; some 

people suffer many. The severity of symptoms varies among 

individuals and also over time. 

Depression

• Persistent sad, anxious, or "empty" mood 

• Feelings of hopelessness, pessimism 

• Feelings of guilt, worthlessness, helplessness 

• Loss of interest or pleasure in hobbies and activities that 

were once enjoyed, including sex 

• Decreased energy, fatigue, being "slowed down" 

• Difficulty concentrating, remembering, making decisions 

• Trouble sleeping, early-morning awakening, or 

oversleeping 

• Appetite and/or weight changes 

• Thoughts of death or suicide, or suicide attempts 

• Restlessness, irritability 

• Persistent physical symptoms, such as headaches, 

digestive disorders, and chronic pain, which do not 

respond to routine treatment 

"You don't have any interest in thinking about the future, 

because you don't feel that there is going to be any

future." 

 -Shawn Colten, National Diving Champion 

6 
"I wouldn't feel rested at all. I'd always feel tired. I could 

get from an hour's sleep to eight hours sleep and I would

always feel tired."

 -Rene Ruballo, Police Officer 

Mania 

• Abnormal or excessive elation 

• Unusual irritability 

• Decreased need for sleep 

• Grandiose notions 

• Increased talking 

• Racing thoughts 

• Increased sexual desire 

• Markedly increased energy 

• Poor judgment 

• Inappropriate social behavior 

Co-Occurrence of Depression 

with Other Illnesses 

Depression can coexist with other illnesses. In such cases, it

is important that the depression and each co-occurring 

illness be appropriately diagnosed and treated. 

Research has shown that anxiety disorders, which 

include post-traumatic stress disorder (PTSD), obsessivecompulsive disorder, panic disorder, social phobia, and 

generalized anxiety disorder, commonly accompany 

depression.5,6

 Depression is especially prevalent among 

people with PTSD, a debilitating condition that can occur 

after exposure to a terrifying event or ordeal in which grave 

physical harm occurred or was threatened. Traumatic events 

that can trigger PTSD include violent personal assaults such 

as rape or mugging, natural disasters, accidents, terrorism, 

and military combat. PTSD symptoms include: reexperiencing the traumatic event in the form of flashback 

7 
episodes, memories, or nightmares; emotional numbness; 

sleep disturbances; irritability; outbursts of anger; intense 

guilt; and avoidance of any reminders or thoughts of the 

ordeal. In one NIMH—supported study, more than 40 

percent of people with PTSD also had depression when 

evaluated at one month and four months following the 

traumatic event.7

Substance use disorders (abuse or dependence) also 

frequently co-occur with depressive disorders.5,6

 Research 

has revealed that people with alcoholism are almost twice as 

likely as those without alcoholism to also suffer from major 

depression.6

 In addition, more than half of people with bipolar

disorder type I (with severe mania) have a co-occurring 

substance use disorder.8

Depression has been found to occur at a higher rate 

among people who have other serious illnesses such as 

heart disease, stroke, cancer, HIV, diabetes, and 

Parkinson's.6,9

 Symptoms of depression are sometimes 

mistaken for inevitable accompaniments to these other 

illnesses. However, research has shown that the cooccurring depression can and should be treated, and that in 

many cases treating the depression can also improve the 

outcome of the other illnesses. 

Causes of Depression 

Substantial evidence from neuroscience, genetics, and 

clinical investigation shows that depressive illnesses are 

disorders of the brain. However, the precise causes of these

illnesses continue to be a matter of intense research. 

Modern brain-imaging technologies are revealing that in 

depression, neural circuits responsible for the regulation of 

moods, thinking, sleep, appetite, and behavior fail to function

properly, and that critical neurotransmitters—chemicals used

by nerve cells to communicate—are out of balance. Genetics 

research indicates that risk for depression results from the 

influence of multiple genes acting together with 

8 
environmental or other nongenetic factors. Studies of brain 

chemistry and the mechanisms of action of antidepressant 

medications continue to inform our understanding of the 

biochemical processes involved in depression. 

Very often, a combination of genetic, cognitive, and 

environmental factors is involved in the onset of a depressive

disorder.10 Trauma, loss of a loved one, a difficult 

relationship, a financial problem, or any stressful change in 

life patterns, whether the change is unwelcome or desired, 

can trigger a depressive episode in vulnerable individuals. 

Later episodes of depression may occur without an obvious 

cause. 

In some families, depressive disorders seem to occur 

generation after generation; however, they can also occur in 

people who have no family history of these illnesses.11

Whether inherited or not, depressive disorders are 

associated with changes in brain structures or brain function, 

which can be seen using modern brain imaging 

technologies.

12,13 

Men and Depression 

Researchers estimate that at least six million men in the 

United States suffer from a depressive disorder every year.3

Research and clinical evidence reveal 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.14,15 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.15 

"I'd drink and I'd just get numb. I'd get numb to try to 

numb my head. I mean, we're talking many, many beers 

9 
to get to that state where you could shut your head off, 

but then you wake up the next day and it's still there. 

Because you have to deal with it, it doesn't just go away.

It isn't a two-hour movie and then at the end it goes 'The 

End' and you press off. I mean it's a twenty-four hour a 

day movie and you're thinking there is no end. It's 

horrible."

 -Patrick McCathern, First Sergeant, U.S. Air Force, 

 Retired 

Men are more likely than women to report alcohol and drug 

abuse or dependence in their lifetime;16 however, there is 

debate among researchers as to whether substance use is a

"symptom" of underlying depression in men, or a cooccurring condition that more commonly develops in men. 

Nevertheless, substance use can mask depression, making it 

harder to recognize depression as a separate illness that 

needs treatment. 

Instead of acknowledging their feelings, asking for help, 

or seeking appropriate treatment, men may turn to alcohol or 

drugs when they are depressed, or become frustrated, 

discouraged, angry, irritable and, sometimes, violently 

abusive. Some men deal with depression 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.15

"When I was feeling depressed I was very reckless with 

my life. I didn't care about how I drove, I didn't care 

about walking across the street carefully, I didn't care 

about dangerous parts of the city. I wouldn't be affected 

by any kinds of warnings on travel or places to go. I 

didn't care. I didn't care whether I lived or died and so I 

was going to do whatever I wanted whenever I wanted. 

10 
And when you take those kinds of chances, you have a 

greater likelihood of dying."

 -Bill Maruyama, Lawyer 

Four times as many men as women die by suicide in the 

United States, even though women make more suicide 

attempts during their lives.

17,18 In addition to the fact that the 

methods men use to attempt suicide are generally more 

lethal than those methods used by women, there may be 

other issues that protect women against suicide death. In 

light of research indicating that suicide is often associated

with depression,19 the alarming suicide rate among men may 

reflect the fact that men are less likely to seek treatment for 

depression. Many men with depression do not obtain 

adequate diagnosis and treatment, which may be life saving.

More research is needed to understand all aspects of 

depression in men, including how men respond to stress and

feelings associated with depression, how to make them more 

comfortable acknowledging these feelings and getting the 

help they need, and how to train physicians to better 

recognize and treat depression in men. Family members, 

friends, and employee assistance professionals in the 

workplace also can play important roles in recognizing 

depressive symptoms in men and helping them get 

treatment. 

Depression in Elderly Men 

Men must cope with several kinds of stress as they age. If 

they have been the primary wage earners for their families 

and have identified heavily with their jobs, they may feel 

stress upon retirement-loss of an important role, loss of 

self-esteem-that can lead to depression. Similarly, the loss of

friends and family and the onset of other health problems can 

trigger depression. Nevertheless, most elderly people feel 

satisfied with their lives, and it is not "normal" for older adults 

to feel depressed.20 Depression is an illness that can be 

11 
effectively treated, thereby decreasing unnecessary 

suffering, improving the chances for recovery from other 

illnesses, and prolonging productive life. 

However, health care professionals may miss 

depressive symptoms in older patients, who are often 

reluctant to discuss feelings of hopelessness, sadness, loss 

of interest in normally pleasurable activities, or extremely 

prolonged grief after a loss, and who may complain primarily 

of physical symptoms.21 Also, it may be difficult to discern a 

co-occurring depressive disorder in patients who present with

other illnesses, such as heart disease, stroke, or cancer, 

which in themselves may cause depressive symptoms, or 

which may be treated with medications that have side effects 

resembling depression. If a depressive illness is diagnosed, 

treatment with appropriate medication and/or brief 

psychotherapy can help older adults manage both diseases, 

thus enhancing survival and quality of life. 

"As you get sick, as you become drawn in more and 

more by depression, you lose that perspective. Events 

become more irritating, you get more frustrated about 

getting things done. You feel angrier, you feel sadder. 

Everything's magnified in an abnormal way."

 -Paul Gottlieb, Publisher 

The importance of identifying and treating depression in 

older adults is stressed by the statistics on suicide among the 

elderly. There is a common perception that suicide rates are 

highest among the young; however, it is the elderly, 

particularly older white males that have the highest rates. 

Over 70 percent of older suicide victims have been to their 

primary care physician within the month of their death, many 

with a depressive illness that was not detected.22 This has 

led to research efforts to determine how to best improve 

physicians' abilities to detect and treat depression in older 

adults.23

12 
Approximately 80 percent of older adults with depression 

improve when they receive treatment with antidepressant 

medication, psychotherapy, or a combination of both.24 In 

addition, research has shown that a combination of 

psychotherapy and antidepressant medication is highly 

effective for reducing recurrences of depression among older 

adults.25 Psychotherapy alone has been shown to prolong 

periods of good health free from depression, and is 

particularly useful for older patients who cannot or will not 

take medication.20 Improved recognition and treatment of 

depression in late life will make those years more enjoyable 

and fulfilling for the depressed elderly person, the family, and 

caregivers. 

Depression in Boys and Adolescent 

Males

Only in the past two decades has depression in children 

been taken very seriously. An NIMH-sponsored study of 9- to 

17-year-olds estimates that the prevalence of any depressive 

disorder is more than 6 percent in a 6-month period, with 4.9 

percent having major depression.26 Before puberty, boys and 

girls are equally likely to develop depressive disorders. After 

age 14, however, females are twice as likely as males to 

have major depression or dysthymia.27 The risk of developing 

bipolar disorder remains approximately equal for males and 

females throughout adolescence and adulthood.

Research has revealed that depression is occurring 

earlier in life today than in past decades.28 In addition, 

research has shown that early-onset depression often 

persists, recurs, and continues into adulthood, and that 

depression in youth may also predict more severe illness in 

adult life.29 Depression in young people frequently co-occurs 

with other mental disorders, most commonly anxiety, 

disruptive behavior, or substance abuse disorders, as well as

with other serious illnesses such as diabetes.30,31 The 

depressed younger child may say he is sick, refuse to go to 

13 
school, cling to a parent, or worry that the parent may die. 

The depressed older child may sulk, get into trouble at 

school, be negative, grouchy, and feel misunderstood. 

Among both children and adolescents, depressive 

disorders confer an increased risk for illness and 

interpersonal and psychosocial difficulties that persist long

after the depressive episode is resolved; in adolescents there 

is also an increased risk for substance abuse and suicidal

behavior.29,32,33 Unfortunately, these disorders often go 

unrecognized by families and physicians alike. Signs of 

depressive disorders in young people are often viewed as 

normal mood swings typical of a particular developmental 

stage. In addition, health care professionals may be reluctant 

to prematurely "label" a young person with a mental illness 

diagnosis. However, early diagnosis and treatment of 

depressive disorders are critical to healthy emotional, social, 

and behavioral development. 

Although the scientific literature on treatment of children 

and adolescents with depression is far less extensive than 

that for adults, a number of recent studies have confirmed 

the short-term efficacy and safety of treatments for 

depression in youth. Larger research studies on treatments 

are underway to determine which ones work best for which 

youngsters. Additional research is needed on how to best 

incorporate these treatments into primary care practice. 

Bipolar disorder, although rare in young children, can 

appear in both children and adolescents.34 The unusual shifts 

in mood, energy and functioning that are characteristic of

bipolar disorder may begin with manic, depressive, or mixed 

manic and depressive symptoms. It is more likely to affect 

the children of parents who have the illness. Twenty to 40 

percent of adolescents with major depression go on to reveal 

bipolar disorder within five years after the onset of

depression.35

Depression in children and adolescents is associated 

with an increased risk of suicidal behaviors.29,36 This risk may 

rise, particularly among adolescent males, if the depression 

is accompanied by conduct disorder and alcohol or other 

substance abuse.37 In 2000, suicide was the third leading 

14 
cause of death among young males, age 10 to 24.

38 NIMHsupported researchers found that among adolescents who 

develop major depressive disorder, as many as seven 

percent may die by suicide in the young adult years.29

Therefore, it is important for doctors and parents to take 

seriously any remarks about suicide.

NIMH researchers are developing and testing various 

interventions to prevent suicide in children and adolescents. 

Early diagnosis and treatment, accurate evaluation of 

suicidal thinking, and limiting young people's access to lethal 

agents—including firearms and medications—may hold the 

greatest suicide prevention value. 

Suicide 

"You are pushed to the point of considering suicide, 

because living becomes very painful. You are looking for 

a way out, you're looking for a way to eliminate this 

terrible psychic pain. And I remember, I never really tried 

to commit suicide, but I came awful close, because I 

used to play matador with buses. You know, I would 

walk out into the traffic of New York City, with no 

reference to traffic lights, red or green, almost hoping 

that I would get knocked down."

-Paul Gottlieb, Publisher

Sometimes depression can cause people to feel like putting 

themselves in harm's way, or killing themselves. Although the 

majority of people with depression do not die by suicide, 

having depression does increase suicide risk compared to 

people without depression. 

If you are thinking about suicide, get help immediately:

• Call your doctor's office. 

• Call 911 for emergency services. 

• Go to the emergency room of the nearest hospital 

15 
• Ask a family member or friend to take you to the hospital 

or call your doctor. 

• Call 1-800-SUICIDE (1-800-784-2433), the toll-free, 24-

hour hotline of the National Hopeline Network sponsored 

by the Kristin Brooks Hope Center, to be connected to a 

trained counselor at a suicide crisis center nearest you. 

Diagnostic Evaluation and Treatment 

"Your tendency is just to wait it out, you know, let it get 

better. You don't want to go to the doctor. You don't 

want to admit to how bad you're really feeling." 

 -Paul Gottlieb, Publisher 

 

The first step to getting appropriate treatment for depression

is a physical examination by a physician. Certain medications 

as well as some medical conditions such as a viral infection,

thyroid disorder, or low testosterone level can cause the 

same symptoms as depression, and the physician should 

rule out these possibilities through examination, interview, 

and lab tests. If no such cause of the depressive symptoms

is found, a psychological evaluation for depression should be 

done by the physician or by referral to a mental health 

professional. 

A good diagnostic evaluation will include a complete 

history of symptoms, i.e., when they started, how long they 

have lasted, how severe they are, whether the patient had 

them before and, if so, whether the symptoms were treated 

and what treatment was given. The doctor should ask about 

alcohol and drug use, and if the patient has thoughts about 

death or suicide. Further, a history should include questions 

about whether other family members have had a depressive 

illness and, if treated, what treatments they may have 

received and if they were effective. Last, a diagnostic 

evaluation should include a mental status examination to 

determine if speech, thought patterns, or memory has been 

affected, as sometimes happens with depressive disorders.

16 
Treatment choice will depend on the patient's diagnosis, 

severity of symptoms, and preference. There are a variety of

treatments, including medications and short-term 

psychotherapies (i.e., "talking" therapies), which have proven 

effective for depressive disorders. In general, severe 

depressive illnesses, particularly those that are recurrent, will 

require a combination of treatments for the best outcome. 

Medications

There are several types of medications used to treat 

depression. These include newer antidepressant

medications—chiefly the selective serotonin reuptake 

inhibitors (SSRIs) —and older ones—the tricyclics and the 

monoamine oxidase inhibitors (MAOIs). The SSRIs, and 

other newer medications that affect neurotransmitters such 

as dopamine or norepinephrine, generally have fewer side 

effects than tricyclics. Sometimes the doctor will try a variety 

of antidepressants before finding the most effective 

medication or combination of medications for the patient. 

Sometimes the dosage must be increased to be effective. 

Although some improvements may be seen in the first couple 

of weeks, antidepressant medications must be taken 

regularly for three to four weeks (in some cases, as many as 

eight weeks) before the full therapeutic effect occurs. 

Patients often are tempted to stop medication too soon. 

They may feel better and think they no longer need the 

medication, or they may think it isn't helping at all. It is 

important to keep taking medication until it has a chance to 

work, though side effects (see section on Side Effects) may 

appear before antidepressant activity does. Once the person

is feeling better, it is important to continue the medication for 

at least four to nine months to prevent a relapse into 

depression. Some medications must be stopped gradually to 

give the body time to adjust, and many can produce 

withdrawal symptoms if discontinued abruptly. Therefore, 

medication should never be discontinued without talking 

to your doctor about it. For individuals with bipolar disorder 

and those with chronic or recurrent major depression, 

medication may have to be maintained indefinitely. 

17 
Research has shown that people with bipolar disorder 

are at risk of switching into mania, or of developing rapid 

cycling episodes, during treatment with antidepressant 

medication.39 Therefore, "mood-stabilizing" medications 

generally are required, alone or in combination with 

antidepressants, to protect people with bipolar disorder from

this switch. Lithium and valproate (Depakote®) are the most 

commonly used mood-stabilizing drugs today. However, the 

potential mood-stabilizing effects of newer medications 

continue to be evaluated through research. 

Medications for depressive disorders are not habitforming. Nevertheless, as is the case with any type of 

medication prescribed for more than a few days, these 

treatments have to be carefully monitored to see if the most 

effective dosage is being given. The doctor will check the 

dosage of each medicine and its effectiveness regularly. 

For the small number of people for whom MAO inhibitors 

are the best treatment, it is necessary to avoid certain foods 

that contain high levels of tyramine, including many cheeses,

wines, and pickles, as well as medications such as 

decongestants. The interaction of tyramine with MAOIs can 

bring on a hypertensive crisis, a sharp increase in blood 

pressure that can lead to a stroke. The doctor should furnish 

a complete list of prohibited foods that the patient should 

carry at all times. Other forms of antidepressants require no 

food restrictions. Efforts are underway to develop a "skin 

patch" system for one of the newer MAOIs, selegiline; if 

successful, this may be a more convenient and safer 

medication option than the older MAOI tablets. 

Medications of any kind—prescribed, over-thecounter, or borrowed—should never be mixed without 

consulting a doctor. Other health professionals, such as a

dentist or other medical specialist, who may prescribe a drug 

should be told of the medications the patient is taking. Some 

medications, although safe when taken alone can, if taken 

with others, cause severe and dangerous side effects. 

Alcohol, including wine, beer, and hard liquor, or street 

drugs may reduce the effectiveness of antidepressants and 

18 
should be avoided. However, some people who have not had 

a problem with alcohol abuse or dependence may be 

permitted by their doctor to use a modest amount of alcohol 

while taking one of the newer antidepressants. 

Antianxiety drugs or sedatives are not antidepressants. 

They are sometimes prescribed along with antidepressants, 

but they are not effective when taken alone for a depressive 

disorder. Stimulants, such as amphetamines, are also not 

effective antidepressants, but they are used occasionally 

under close supervision in medically ill depressed patients. 

Lithium has for many years been the treatment of choice 

for bipolar disorder, as it can be effective in smoothing out 

the mood swings common to this illness. Its use must be 

carefully monitored, as the range between an effective dose 

and a toxic one is small. If a person has preexisting thyroid, 

kidney, or heart disorders or epilepsy, lithium may not be 

recommended. Fortunately, other medications have been 

found to be of benefit in controlling mood swings. Among 

these are two mood-stabilizing anticonvulsants, valproate 

(Depakote®) and carbamazepine (Tegretol®). Both of these 

medications have gained wide acceptance in clinical 

practice, and valproate has been approved by the Food and 

Drug Administration for first-line treatment of acute mania. 

Other anticonvulsants that are being used now include 

lamotrigine (Lamictal®), topiramate (Topamax®), and 

gabapentin (Neurontin®); however, their role in the treatment 

of bipolar disorder is not yet proven and remains under 

study. 

 Most people who have bipolar disorder take more than 

one medication including, along with lithium and/or an 

anticonvulsant, a medication for accompanying agitation, 

anxiety, depression, or insomnia. Finding the best possible 

combination of these medications is of utmost importance to 

the patient and requires close monitoring by the physician. 

Questions about any medication prescribed, or 

problems that may be related to it, should be discussed 

with your doctor.

19 
Side Effects

Before starting a new medication, ask the doctor to tell you 

about any side effects you may experience. Antidepressants 

may cause mild and, usually, temporary side effects 

(sometimes referred to as adverse effects) in some people. 

Typically these are annoying, but not serious. However, any 

unusual reactions or side effects, or those that interfere with 

functioning, should be reported to the doctor immediately. 

The most common side effects of the newer 

antidepressants (SSRIs and others) are: 

• Headache - this will usually go away. 

• Nausea - this is also temporary, but even when it occurs, 

it is transient after each dose. 

• Nervousness and insomnia (trouble falling asleep or 

waking often during the night) - these may occur during 

the first few weeks; dosage reductions or time will usually 

resolve them. 

• Agitation (feeling jittery) - if this happens for the first time 

after the drug is taken and is more than transient, the 

doctor should be notified.

• Sexual problems - the doctor should be consulted if the 

problem is persistent or worrisome. Although depression 

itself can lower libido and impair sexual performance, it 

has been clearly established that SSRIs and other 

strongly serotonergic antidepressants (e.g., the tricyclic 

antidepressant clomipramine) provoke new, dosedependant sexual dysfunction independent of their 

therapeutic activity in both men and women. These side 

effects can affect more than half of adults taking SSRIs. 

In men, common problems include reduced sexual drive, 

erectile dysfunction, and delayed ejaculation. 

In some cases of sexual dysfunction, the symptoms 

improve with the development of tolerance or lowering of the 

dose of medication; drug "holidays" in anticipation of sexual 

activity have proved to be successful for some patients 

taking shorter-acting SSRIs but are not feasible in the case 

of fluoxetine (Prozac®). Data describing differences among 

the SSRIs are limited, and there are no data showing a 

20 
clinical benefit with respect to sexual dysfunction as a result 

of switching medications within this class. If an 

antidepressant must be changed, one from a different class 

should be substituted; bupropion (Wellbutrin®), mirtazapine 

(Remeron®), nefazodone (Serzone®), and venlafaxine 

(Effexor®) appear to be good choices on the basis of these 

side effects. Guided by a limited number of studies, some 

clinicians treating men with antidepressant-associated sexual 

dysfunction report improvement with the addition of 

bupropion (Wellbutrin®), buspirone (BuSpar®), or sildenafil 

(Viagra®)

40 to ongoing treatment. Be sure to discuss the 

various options with your doctor, as there may be other 

interventions that can help. 

Tricyclic antidepressants have different types of side 

effects: 

• Dry mouth - it is helpful to drink sips of water; chew 

sugarless gum; clean teeth daily. 

• Constipation - bran cereals, prunes, fruit, and vegetables 

should be in the diet. 

• Bladder problems - emptying the bladder may be

troublesome, and the urine stream may not be as strong 

as usual; the doctor should be notified if there is marked 

difficulty or pain; may be particularly problematic in older 

men with enlarged prostate conditions. 

• Sexual problems - sexual functioning may change; men 

may experience some loss of interest in sex, difficulty in 

maintaining an erection or achieving orgasm. If 

worrisome, these side effects should be discussed with 

the doctor. 

• Blurred vision - this will pass soon and will not usually 

necessitate new glasses. 

• Dizziness - rising from the bed or chair slowly is helpful. 

• Drowsiness as a daytime problem - this usually passes 

soon. A person feeling drowsy or sedated should not 

drive or operate heavy equipment. The more sedating 

antidepressants are generally taken at bedtime to help 

sleep and minimize daytime drowsiness. 

21 
Psychotherapies

Several forms of psychotherapy, including some short-term 

(10-20 weeks) therapies, can help people with depressive 

disorders. Two of the short-term psychotherapies that 

research has shown to be effective for depression are 

cognitive-behavioral therapy (CBT) and interpersonal therapy 

(IPT). Cognitive-behavioral therapists help patients change 

the negative thinking and behavior patterns that contribute to

or result from depression. Through verbal exchange with the 

therapist, as well as "homework" assignments between 

therapy sessions, CBT helps patients gain insight into and 

resolve problems related to their depression. Interpersonal 

therapists help patients work through disturbed personal 

relationships that may be contributing to or worsening their 

depression. Psychotherapy is offered by a variety of licensed 

mental health providers, including psychiatrists, 

psychologists, social workers, and mental health counselors.

For many depressed patients, especially those with 

moderate to severe depression, a combination of 

antidepressant medication and psychotherapy is the 

preferred approach to treatment. Some psychiatrists offer 

both types of intervention. Alternatively, in many cases two 

mental health professionals collaborate in the treatment of a 

person with depression; for example, a psychiatrist or other 

physician, such as a family doctor, may prescribe medication 

while a nonmedical therapist provides ongoing 

psychotherapy. 

"You start to have these little thoughts, 'Wait, maybe I 

can get through this. Maybe these things that are 

happening to me aren't so bad.' And you start thinking to 

yourself, 'Maybe I can deal with things for now.' And it's 

just little tiny thoughts until you realize that it's gone and 

then you go, 'Oh my God, thank you, I don't feel sad 

anymore.' And then when it was finally gone, when I felt 

happy, I was back to the usual things that I was doing in 

my life. You get so happy because you think to yourself,

22 
'I never thought it would leave.' "

 -Shawn Colten, National Diving Champion 

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is another treatment option 

that may be particularly useful for individuals whose 

depression is severe or life threatening, or who cannot take 

antidepressant medication. ECT often is effective in cases 

where antidepressant medications do not provide sufficient 

relief of symptoms. The exact mechanisms by which ECT 

exerts its therapeutic effect are not yet known.41

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) generalized 

seizure within the brain, which is necessary for therapeutic 

efficacy. The person receiving ECT does not consciously 

experience the electrical stimulus. 

A typical course of ECT entails 6 to 12 treatments, 

administered at a rate of three times per week, on either an 

inpatient or outpatient basis. To sustain the response to ECT, 

continuation treatment, often in the form of antidepressant 

and/or mood stabilizer medication, must be instituted. Some 

individuals may require maintenance ECT, which is delivered

on an outpatient basis at a rate of one treatment weekly to as 

infrequently as monthly. The most common side effects of 

ECT are confusion and memory loss for events surrounding 

the period of ECT treatment. The confusion and 

disorientation experienced upon awakening after ECT 

typically clear within an hour. More persistent memory 

problems are variable and can be minimized with the use of 

modern treatment techniques, such as application of both 

stimulus electrodes to the right side of the head (unilateral 

ECT).41,42

Herbal Therapy

In the past several years, there has been an increase in 

23 
public interest in the use of herbs for the treatment of both 

depression and anxiety. The extract from St. John's wort 

(Hypericum perforatum), a wild-growing plant with yellow 

flowers, has been used extensively in Europe as a treatment 

for mild to moderate depression, and it now ranks among the 

top-selling botanical products in the United States. Because 

of the increase in Americans' use of St. John's wort and the 

need to answer important remaining questions about the 

herb's efficacy and long-term use for depression, the 

National Institutes of Health (NIH) conducted a four-year, $6 

million clinical trial to determine whether a well-standardized 

extract of St. John's wort is effective in the treatment of 

adults suffering from major depression of moderate severity. 

The trial found that St. John's wort was no more effective for 

treating major depression of moderate severity than 

placebo.43 More research is needed to confirm the role of the 

herb in managing less severe forms of depression. 

The Food and Drug Administration issued a Public 

Health Advisory on February 10, 2000 about the use of St. 

John's wort. It stated that the herb appears to affect an 

important metabolic pathway that is used by many drugs 

prescribed to treat conditions such as heart disease, 

depression, seizures, certain cancers, and rejection of organ 

transplants. Also, St. John's wort reduces blood levels of 

some HIV medications. If taken together, the combination 

could allow the AIDS virus to rebound, perhaps in a drugresistant form. (See the alert on the NIMH Web site: 

http://www.nimh.nih. gov/events/stjohnwort.cfm). Health care

providers should alert their patients about these potential 

drug interactions, and patients should always consult their 

health care provider before taking any herbal supplement. 

How to Help Yourself if You Are 

Depressed 

"It affects the way you think. It affects the way you feel. It 

just simply invades every pore of your skin. It's a blanket 

24 
that covers everything. The act of pretending to be well 

was so exhausting. All I could do was shut down. At 

times you just say 'It's enough already. ' "

 -Steve Lappen, Writer 

Depressive disorders make one feel exhausted, worthless, 

helpless, and hopeless. Such negative thoughts and feelings 

make some people feel like giving up. It is important to 

realize that these negative views are part of the depression 

and typically do not accurately reflect the actual 

circumstances. Negative thinking fades as treatment begins 

to take effect. In the meantime: 

• Mild exercise, going to a movie, a ballgame, or 

participating in religious, social, or other activities may 

help. 

• Set realistic goals in light of the depression and assume a 

reasonable amount of responsibility. 

• Break large tasks into small ones, set some priorities, 

and do what you can as you can 

• 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. 

• Expect your mood to improve gradually, not immediately. 

Feeling better takes time. Often during treatment of 

depression, sleep and appetite will begin to improve 

before depressed mood lifts. 

• It is advisable to postpone important decisions until the 

depression has lifted. Before deciding to make a 

significant transition—change jobs, get married or 

divorced—discuss it with others who know you well and 

have a more objective view of your situation. 

• People rarely "snap out of" a depression. But they can 

feel a little better day-by-day. 

• Remember, positive thinking will replace the negative 

thinking that is part of the depression and will disappear 

as your depression responds to treatment. 

• Let your family and friends help you. 

25 
How Family and Friends Can Help 

The most important thing anyone can do for a man who may 

have depression is to help him get to a doctor for a 

diagnostic evaluation and treatment. First, try to talk to him 

about depression — help him understand that depression is 

a common illness among men and is nothing to be ashamed 

about. Perhaps share this booklet with him. Then encourage 

him to see a doctor to determine the cause of his symptoms 

and obtain appropriate treatment. 

Occasionally, you may need to make an appointment for 

the depressed person and accompany him to the doctor. 

Once he is in treatment, you may continue to help by 

encouraging him to stay with treatment until symptoms begin 

to lift (several weeks), or to seek different treatment if no 

improvement occurs. This may also mean monitoring 

whether he is taking prescribed medication and/or attending 

therapy sessions. Encourage him to be honest with the 

doctor about his use of alcohol and prescription or

recreational drugs, and to follow the doctor's orders about the 

use of these substances while on antidepressant medication.

The second most important thing is to offer emotional 

support to the depressed person. This involves 

understanding, patience, affection, and encouragement. 

Engage him in conversation and listen carefully. Do not 

disparage the feelings he may express, but point out realities 

and offer hope. Do not ignore remarks about suicide. 

Report them to the depressed person's doctor. In an 

emergency, call 911. Invite him for walks, outings, to the 

movies, and other activities. Be gently insistent if your 

invitation is refused. Encourage participation in some 

activities that once gave pleasure, such as hobbies, sports, 

religious or cultural activities, but do not push him to 

undertake too much too soon. The depressed person needs 

diversion and company, but too many demands can increase 

feelings of failure. 

26 
Do not accuse the depressed person of faking illness or of 

laziness, or expect him "to snap out of it." Eventually, with 

treatment, most people do get better. Keep that in mind, and 

keep reassuring him that, with time and help, he will feel 

better. 

Where to Get Help 

 If unsure where to go for help, talk to someone you trust who 

has experience in mental health—for example, a doctor, 

nurse, social worker, or religious counselor. Ask their advice 

on where to seek treatment. If there is a university nearby, its 

departments of psychiatry or psychology may offer private 

and/or sliding-scale fee clinic treatment options. Otherwise, 

check the Yellow Pages under "mental health," "health," 

"social services," "suicide prevention," "crisis intervention 

services," "hotlines," "hospitals," or "physicians" for phone 

numbers and addresses. In times of crisis, the emergency 

room doctor at a hospital may be able to provide temporary 

help for a mental health problem, and will be able to tell you 

where and how to get further help. 

Listed below are the types of people and places that will 

make a referral to, or provide, diagnostic and treatment 

services. 

• Family doctors 

• Mental health specialists, such as psychiatrists, 

psychologists, social workers, or mental health 

counselors 

• Religious leaders/counselors 

• Health maintenance organizations 

• Community mental health centers 

• Hospital psychiatry departments and outpatient clinics 

• University- or medical school-affiliated programs 

• State hospital outpatient clinics 

• Social service agencies 

• Private clinics and facilities 

• Employee assistance programs 

• Local medical and/or psychiatric societies 

27 
Within the Federal government, the Substance Abuse and 

Mental Health Services Administration (SAMHSA) offers a 

"Services Locator" for mental health and substance abuse 

treatment programs and resources nationwide. Visit their 

Web site at http://www.mentalhealth.samhsa.gov/databases/

or call toll-free, 1-800-789-2647. 

Conclusion 

Have you known a man who is grumpy, irritable, and has no 

sense of humor? Maybe he drinks too much or abuses 

drugs. Maybe he physically or verbally abuses his wife and 

his kids. Maybe he works all the time, or compulsively seeks 

thrills in high-risk behavior. Or maybe he seems isolated, 

withdrawn, and no longer interested in the people or activities

he used to enjoy. 

Perhaps this man is you. If so, it is important to 

understand that there is a disease of the brain called 

depression that may be underlying these feelings and 

behaviors. It's real: scientists have developed sensitive 

imaging devices that enable us to see it in the brain. And it's 

treatable: more than 80 percent of those suffering from 

depression respond to existing treatments,44 and new ones 

are continually becoming available and helping more people. 

Talk to a healthcare provider about how you are feeling, and

ask for help.

Or perhaps this man is someone you care about. Try to 

talk to him, or to someone who has a chance of getting 

through to him. Help him to understand that depression is a 

common illness among men and is nothing to be ashamed 

about. Encourage him to see a doctor and get an evaluation 

for depression. 

For most men with depression, life doesn't have to be so 

dark and hopeless. Life is hard enough as it is; and treating 

depression can free up vital resources to cope with life's 

challenges effectively. When a man is depressed, he's not 

the only one who suffers. His depression also darkens the 

lives of his family, his friends, virtually everyone close to him. 

28 
Getting him into treatment can send ripples of healing and 

hope into all of those lives. 

 Depression is a real illness; it is treatable; and men can 

have it. It takes courage to ask for help, but help can make 

all the difference. 

"And pretty soon you start having good thoughts about 

yourself and that you're not worthless and you kind of 

turn your head over your shoulder and look back at that, 

that rutted, muddy, dirt road that you just traveled and 

now you're on some smooth asphalt and go, 'Wow, what 

a trip. Still got a ways to go, but I wouldn't want to go 

down that road again.' "

 -Patrick McCathern, First Sergeant, U.S. Air Force, Retired

For More Information 

National Institute of Mental Health

Office of Communications 

6001 Executive Boulevard, Room 8184, MSC 9663 

Bethesda, MD 20892-9663 

Toll-Free: 1-866-227-NIMH (-6464) 

Phone: 1-301-443-4513 

FAX: 1-301-443-4279 

TTY: 1-301-443-8431 

FAX4U: 1-301-443-5158 

Web site: http://www.nimh.nih.gov

E-mail: nimhinfo@nih.gov 

The Federal government agency whose mission is to reduce 

the burden of mental illness and behavioral disorders through 

research on mind, brain, and behavior. NIMH is a part of the 

National Institutes of Health, U.S. Department of Health and 

Human Services. 

29 
Substance Abuse and Mental Health Services 

Administration

National Mental Health Information Center 

P.O. Box 42557 

Washington, DC 20015 

Toll-Free: 1-800-789-2647 

FAX: 1-301-984-8796 

TDD: 1-866-889-2647 

Web site: http://www.mentalhealth.org 

E-mail: info@mentalhealth.org 

SAMHSA's National Mental Health Information Center 

provides the public information on mental health services and 

referrals to Federal, State, or local resources for more 

information and help. SAMHSA is an agency of the U.S. 

Department of Health and Human Services. 

Depression and Bipolar Support Alliance (formerly

the National Depressive and Manic-Depressive 

Association) 

730 N. Franklin Street, Suite 501 

Chicago, IL 60601-7224 

Toll-Free: 1-800-826-3632 

Phone: 1-312-642-0049 

FAX: 1-312-642-7243 

Web site: http://www.dbsalliance.org 

A patient-directed organization whose mission is to improve 

the lives of people living with mood disorders. 

National Alliance for the Mentally Ill 

Colonial Place Three 

2107 Wilson Boulevard, Suite 300 

Arlington, VA 22201 

Toll-Free: 1-800-950-NAMI (-6264) 

Phone: 1-703-524-7600 

FAX: 1-703-524-9094 

TDD: 1-888-344-6264 

Web site: http://www.nami.org 

A support and advocacy organization of consumers, families, 

and friends of people with severe mental illness-over 1,200 

30 
state and local affiliates. Local affiliates often give guidance 

in finding treatment. 

National Foundation for Depressive Illness, Inc. 

PO Box 2257 

New York, NY 10116 

Toll-Free: 1-800-239-1265 

Phone: 1-212-268-4260 

Web site: http://www.depression.org 

A foundation that informs the public about depressive illness 

and its treatability and promotes programs of research, 

education, and treatment. 

National Mental Health Association 

2001 N. Beauregard Street, 12th Floor 

Alexandria, VA 22311 

Toll-Free: 1-800-969-NMHA (-6642) 

Phone: 1-703-684-7722 

FAX: 1-703-684-5968 

TTY: 1-800-433-5959 

Web site: http://www.nmha.org 

An association that works with more than 340 affiliates 

nationwide to promote mental health through advocacy, 

education, research, and services.

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The following staff of the NIMH Office of Communications were contributing writers 

and editors of this booklet: Rayford Kytle, Margaret Strock, Melissa Spearing, 

Clarissa Wittenberg, Daisy Whittemore, Ruth Dubois, and Lisa D. Alberts. Scientific 

review was provided by Matthew V. Rudorfer, MD, and Jane L. Pearson, PhD, of 

NIMH. 

This publication is in the public domain and may be used and reprinted 

without permission from the NIMH. Citation of NIMH as the source is 

appreciated. 

37