PLAIN TALK ABOUT DEPRESSION

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Plain Talk About...

DEPRESSION

What Is A Depressive Disorder?

Types of Depression

Symptoms of Depression and Mania

Causes of Depression

Diagnostic Evaluation and Treatment

Antidepressant Medications

Side Effects

Psychotherapies

Helping Yourself

Family and Friends Can Help

Helping the Depressed Person

Where to Get Help

Further Information

During any 1 year period, 17.6 million American adults or 10% of the population suffer from a depressive illness. The

cost in human suffering cannot be estimated. Depressive illnesses often interfere with normal functioning and cause pain

and suffering not only to those who have a disorder, but also to those who care about them. Serious depression can

destroy family life as well as the life of the ill person.

Possibly the saddest fact about depression is that much of this suffering is unnecessary. Most people with a depressive

illness do not seek treatment, although the great majority--even those with the severest disorders--can be helped. Thanks

to years of fruitful research, the medications and psychosocial therapies that ease the pain of depression are at hand.

Unfortunately, many people do not recognize that they have a treatable illness. Read this flyer to see if you are one of

the many undiagnosed depressed people in this country or if you know someone who is. The information briefly

presented here may help you take the steps that may save your own or someone else's life.

WHAT IS A DEPRESSIVE DISORDER?

A depressive disorder is a "whole-body" illness, involving your body, mood, and thoughts. It affects the way you eat

and sleep, the way you feel about yourself, and the way you think about things. A depressive disorder is not the same as

a passing blue mood. 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, or years. Appropriate treatment, however, can help most people who suffer from depression.

TYPES OF DEPRESSION

Depressive disorders come in different forms, just as do other illnesses, such as heart disease. This pamphlet briefly
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describes three of the most prevalent types of depressive disorders. However, within these types there are variations in

the number of symptoms, their severity, and persistence.

Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work,

sleep, eat, and enjoy once pleasurable activities. These disabling episodes of depression can occur once, twice, or

several times in a lifetime.

A less severe type of depression, dysthymia, involves long- term, chronic symptoms that do not disable, but keep you

from functioning at "full steam" or from feeling good. Sometimes people with dysthymia also experience major

depressive episodes.

Another type is bipolar disorder, formerly called manic- depressive illness. Not nearly as prevalent as other forms of

depressive disorders, bipolar disorder involves cycles of depression and elation or mania. Sometimes the mood switches

are dramatic and rapid, but most often they are gradual. When in the depressed cycle, you can have any or all of the

symptoms of a depressive disorder. When in the manic cycle, any or all symptoms listed under mania may be

experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and

embarrassment. For example, unwise business or financial decisions may be made when an individual is in a manic

phase. Bipolar disorder is often a chronic recurring condition.

SYMPTOMS OF DEPRESSION AND MANIA

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some

many. Also, severity of symptoms varies with individuals.

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

Insomnia, early-morning awakening, or oversleeping

Appetite and/or weight loss or overeating and weight gain

Decreased energy, fatigue, being "slowed down"

Thoughts of death or suicide; suicide attempts

Restlessness, irritability

Difficulty concentrating, remembering, making decisions

Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and

chronic pain

MANIA

Inappropriate elation
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Inappropriate irritability

Severe insomnia

Grandiose notions

Increased talking

Disconnected and racing thoughts

Increased sexual desire

Markedly increased energy

Poor judgment

Inappropriate social behavior.

CAUSES OF DEPRESSION

Some types of depression run in families, indicating that a biological vulnerability can be inherited. This seems to be the

case with bipolar. Studies of families, in which members of each generation develop bipolar disorder, found that those

with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not

true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder has the illness. Apparently

additional factors, possibly a stressful environment, are involved in its onset.

Major depression also seems to occur, generation after generation, in some families. However, it can also occur in

people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated

with having too little or too much of certain neuro-chemicals.

Psychological makeup also plays a role in vulnerability to depression. People who have low self-esteem, who

consistently view themselves and the world with pessimism, or who are readily overwhelmed by stress are prone to

depression.

A serious loss, chronic illness, difficult relationship, financial problem, or any unwelcome change in life patterns can

also trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is

involved in the onset of a depressive disorder.

DIAGNOSTIC EVALUATION AND TREATMENT

The first step to getting appropriate treatment is a complete physical and psychological evaluation to determine whether

you have a depressive illness, and if so what type you have. Certain medications as well as some medical conditions can

cause symptoms of depression and the examining physician should rule out these possibilities through examination,

interview, and lab tests.

A good diagnostic evaluation also will include a complete history of your symptoms, i.e., when they started, how long

they have lasted, how severe they are, whether you've had them before and, if so, whether you were treated and what

treatment you received. Your doctor should ask you about alcohol and drug use, and if you have 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 which were effective.

Last, a diagnostic evaluation will include a mental status examination to determine if your speech or thought patterns or
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memory have been affected, as often happens in the case of a depressive or manic-depressive illness.

Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and

psychotherapies that can be used to treat depressive disorders. Some people do well with psychotherapy, some with

antidepressants. Some do best with combined treatment: medication to gain relatively quick symptom relief and

psychotherapy to learn more effective ways to deal with life's problems. Depending on your diagnosis and severity of

symptoms, you may be prescribed medication and/or treated with one of the several forms of psychotherapy that have

proven effective for depression.

At times, electroconvulsive therapy (ECT) is useful, particularly 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. In recent years, ECT has been much improved. The treatment

is given in the hospital under sedation so that people receiving ECT do not feel pain.

ANTIDEPRESSANT MEDICATIONS

Three groups of antidepressant medications are most often used to treat depressive disorders: tricyclics, monoamine

oxidase inhibitors (MAOIs), and lithium. Lithium is the treatment of choice for bipolar disorder and some forms of

recurring, major depression. Sometimes your doctor will try a variety of antidepressants before finding the medication

or combination of medications most effective for you. Sometimes the dosage must be increased to be effective. Also,

new types of antidepressants are being developed all the time, and one of these may be the best for you.

There are now two new classes of antidepressants which are neither tricyclics nor MAOIs, and which generally lack the

side effects associated with these two traditional classes of drugs. The first of these is fluoxetine, a serotonin re-uptake

inhibitor; the other is bupropion, believed to act on the dopaminergic system.

Patients often are tempted to stop medication too soon. It is important to keep taking medication until your doctor says

to stop, even if you feel better beforehand. Some medications must be stopped gradually to give your body time to

adjust. For individuals with bipolar disorder or chronic major depression, medication may have to become part of

everyday life to avoid disabling symptoms.

Antidepressant drugs are not habit-forming, so you need not be concerned about that. However, as is the case with any

type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if you are

getting the correct dosage. Your doctor will want to check the dosage and its effectiveness regularly.

If you are taking MAO inhibitors, you will have to avoid certain foods, such as cheeses, wines, and pickles. Be sure you

get a complete list of foods you should not eat from your doctor and always carry it with you. Other forms of

antidepressants require no food restrictions.

Never mix medications of any kind--prescribed, over-the counter, or borrowed--without consulting your doctor. Be sure

to tell your dentist or any other medical specialist who prescribes a drug that you are taking antidepressants. Some of the

most benign drugs when taken alone can cause severe and dangerous side effects if taken with others. Some drugs, like

alcohol, reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor.

Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants;

however, they should not be taken alone for a depressive disorder. Sleeping pills and stimulants, such as amphetamines,

are also inappropriate.

Be sure to call your doctor if you have a question about any drug or if you are having a problem you believe is drug

related.
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SIDE EFFECTS

Antidepressants may cause mid and, usually, temporary side effects in some people. Typically these are annoying, but

not serious. However, unusual side effects or those that interfere with functioning should be reported to your doctor. The

most common side effects, and ways to deal with them, are:

Dry mouth--drink lots of water; chew sugarless gum; clean teeth daily.

Constipation--eat bran cereals, prunes, fruit, and vegetables.

Bladder problems--emptying your bladder may be troublesome, and your urine stream may not be as strong as

usual; call your doctor if there is any pain. 

Sexual problems--sexual functioning may change; if worrisome, discuss with your doctor.

Blurred vision--this will pass soon; do not get new glasses.

Dizziness--rise from bed or chair slowly.

Drowsiness--this will pass soon; do not drive or operate heavy equipment if feeling drowsy or sedated.

The newer antidepressants have different types of side effects:

Headache--this will usually go away.

Nausea--even when it occurs, it is transient after each dose.

Nervousness and insomnia--these may occur during the first few weeks; dosage reductions or time will usually

resolve them.

Agitation--if this happens for the first time after the drug is taken and is more than transient, consult your doctor.

PSYCHOTHERAPIES

There are many forms of psychotherapy effectively used to help depressed individuals, including some short term (10-

20 weeks) therapies. "Talking" therapies help patients gain insight into and resolve their problems through verbal "giveand-take" with the therapist. "Behavioral" therapists help patients learn how to obtain more satisfaction and rewards

through their own actions and how to unlearn the behavioral patterns that contribute to their depression.

Two of the short term psychotherapies that research has shown helpful for some forms of depression are Interpersonal

and Cognitive/Behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that

both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of

thinking and behaving often associated with depression.

Psychodynamic therapies, sometimes used to treat depression, focus on resolving the patient's internal psychological

conflicts that are typically thought to be rooted in childhood.

In general, the severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under

special conditions) along with psychotherapy for the best outcome.

HELPING YOURSELF

Depressive disorders make you 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 your situation. Negative thinking fades as treatment begins to take effect. In the

meantime:

Do not set yourself difficult goals or take on a great deal of responsibility.

Break large tasks into small ones, set some priorities, and do what you can as you can.

Do not expect too much from yourself too soon as this will only increase feelings of failure.
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Try to be with other people; it is usually better than being alone.

Participate in activities that may make you feel better.

You might try mild exercise, going to a movie, a ball-game, or participating in religious or social activities.

Don't overdo it or get upset if your mood is not greatly improved right away. Feeling better takes time.

Do not make major life decisions, such as changing jobs, getting married or divorced, without consulting others

who know you well and who have a more objective view of your situation. In any case, it is advisable to postpone

important decisions until your depression has lifted.

Do not expect to snap out of your depression. People rarely do. Help yourself as much as you can, and do not

blame yourself for not being up to par. 

Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression

responds to treatment.

FAMILY AND FRIENDS CAN HELP

Since depression can make you feel exhausted and helpless, you will want and probably need help from others.

However, people who have never had a depressive disorder may not fully understand its effect. They won't mean to hurt

you, but they may say and do things that do. It may help to share this pamphlet with those you most care about so they

can better understand and help you.

HELPING THE DEPRESSED PERSON

The most important thing anyone can do for the depressed person is to help him or her get appropriate diagnosis and

treatment. This may involve encouraging the individual to stay with treatment until symptoms begin to abate (several

weeks), or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment

and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is

taking medication.

The second most important thing is to offer emotional support. 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. Always report them to the depressed person's

therapist.

Invite the depressed person 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 the depressed person to undertake too much too soon. The depressed person needs diversion

and company, but too many demands can increase feelings of failure.

Do not accuse the depressed person of faking illness or of laziness, or expect him or her "to snap out of it." Eventually,

with treatment, most depressed people do get better. Keep that in mind, and keep reassuring the depressed person that,

with time and help, he or she will feel better.

WHERE TO GET HELP

A complete physical and psychological diagnostic evaluation will help you decide the type of treatment that might be

best for you. Listed below are the types of people and places that will make a referral to, or provide, diagnostic and

treatment services. Check the Yellow Pages under "mental health," "health," "social services," "suicide prevention,"

"hospitals," or "physicians" for phone numbers and addresses.

Family doctors
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Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors

Health maintenance organizations

Community mental health centers

Hospital psychiatry departments and outpatient clinics

University- or medical school-affiliated programs

State hospital outpatient clinics

Family service/social agencies

Private clinics and facilities

Employee assistance programs

Local medical and/or psychiatric societies

FURTHER INFORMATION

Write to:

D/ART/Public Inquiries

National Institute of Mental Health

Room 7C-02

5600 Fishers Lane

Rockville, MD 20857

1-800-421-4211

National Alliance for the Mentally Ill

200 North Glebe Road, Suite 1015

Arlington, VA 22203-3754

(703) 524-7600; 1-800-950-NAMI

National Depressive an Manic Depressive Association

730 N. Franklin, Suite 501

Chicago, IL 60601

(312) 642-0049; 1-800-826-3632

National Foundation for Depressive Illness, Inc.

P.O. Box 2257

New York, NY 10016

(212) 268-4260; 1-800-248-4344

National Mental Health Association

1021 Prince Street

Alexandria, VA 22314-2971

(703) 685-7722; 1-800-969-6642

This flier was written by Marilyn Sargent, Office of Scientific Information, National Institute of Mental Health (NIMH)

for the Depression/ Awareness, Recognition, and Treatment (D/ART) program. D/ART is a professional and public
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education program sponsored by NIMH in collaboration with private organizations and citizens. D/ART's goals include

the alleviation of symptoms through effective treatment for the millions of Americans who suffer from depressive

disorders each year. The program is based on more than 40 years of research on the diagnosis and treatment of

depressive disorders.

Message--The National Institute of Mental Health (NIMH), is the U.S. Government agency that supports and conducts

research to improve the diagnosis, treatment, and prevention of mental illness. NIMH- supported studies alleviate

suffering and bring hope to people who have a mental disorder, to those who are at risk of developing one, and to their

families, friends, and coworkers. Thus mental health research benefits millions of Americans and reduces the burden

that mental disorders impose on society as a whole.

NIH Publication No. 94-3561

National Institutes of Health

Printed 1994

This flier is in the public domain and may be used and reprinted without permission. Citation as to source is appreciated

U.S. Department of Health and Human Services

National Institutes of Health

National Institute of Mental Health,

Bulk sales (S/N 017-024-01382-0) by the U.S. Government Printing Office, Superintendent of Documents, Mail Stop:

SSOP, Washington, DC 20402-9328.