Depression

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

This topic covers depression in adults. For information on depression in young people, see the topic Depression in Children and Teens. For information on depression following childbirth, see the topic Postpartum Depression.

What is depression?

Depression is an illness that causes a person to feel sad and hopeless much of the time. It is different from normal feelings of sadness, grief, or low energy.

Anyone can have depression. It often runs in families. But it can also happen to someone who doesn't have a family history of depression. You can have depression one time or many times.

If you think you may be depressed, tell your doctor. There are good treatments that can help you enjoy life again. The sooner you get treatment, the sooner you will feel better.

What causes depression?

The causes of depression are not entirely understood. Things that may trigger depression include:

• Major events that create stress, such as childbirth or a death in the family.
• Illnesses, such as arthritis, heart disease, or cancer.
• Certain medicines, such as steroids or narcotics for pain relief.
• Drinking alcohol or using illegal drugs.

These and other factors can cause certain brain chemicals to get out of balance. As soon as the imbalance is corrected, symptoms of depression generally go away.

What are the symptoms?

Depression can cause different symptoms in different people, and they may be hard to notice at first. For example, a child may seem grouchy and irritable. An older adult may be forgetful. If you think a loved one is depressed, learn more about what symptoms to look for, and urge the person to get help if needed.

People who are depressed may:

• Think and speak more slowly than normal.
• Have trouble concentrating, remembering, and making decisions.
• Have changes in their eating and sleeping habits.
• Lose interest in things they enjoyed before they were depressed.
• Have feelings of guilt and hopelessness, wondering if life is worth living.
• Think a lot about death or suicide.
• Complain about problems that don't have a physical cause, such as headache and stomachache.

All of these symptoms can cause a problem with your quality of life. If you have had a few of these symptoms for at least 2 weeks, talk to your doctor. You may have depression that requires treatment.

If you think you may have depression, take a short quiz to evaluate your symptoms:

Interactive Tool: Are You Depressed?

How is it treated?

Depression is usually treated with counseling or antidepressant medicine, or both. It sometimes takes a few tries to find the right treatment, and it can take several weeks for the medicine to start working. Try to be patient and stay with your treatment.

If you have mild or moderate depression, you may be diagnosed and treated by your family doctor and a therapist or psychologist. If you have severe depression or do not respond to treatment, it may be helpful to see a psychiatrist. This is a medical doctor who specializes in mental health problems. Severe cases of depression may need to be treated in the hospital.

Let your doctor know if you believe you are depressed, because depression is often overlooked. If you are diagnosed with depression, you and your doctor can decide on the best treatment. The earlier you are treated, the more quickly you will recover.¹

How common is depression?

Many people will have depression at some point in their lives. Chances of becoming depressed are higher for certain people. For example:

• Women have depression twice as often as men. But men are more likely to commit suicide because of depression.²
• Separated or divorced people, especially men, are more likely than married people to become depressed.
• People who have a serious illness are more likely to have depression.

If you have had depression before, there is a good chance that it will happen again. Taking your medicines even after you feel better can help keep you from getting depressed again. Some people need to take medicine for the rest of their lives.

What can you do if a loved one has depression?

Depression can lead to suicide. Learn the warning signs of suicide, and if you see them in a loved one, get help.

Watch your loved ones for these warning signs of suicide:

• Planning to, or saying they want to, kill themselves or someone else.
• Having a way to commit suicide, such as having a gun.
• Being out of touch with reality, having severe anxiety, or thinking they hear voices giving them commands.
• Using alcohol or drugs, especially in large amounts.
• Talking, writing, or drawing about death. This includes writing suicide notes and talking about items that can cause physical harm, such as pills, guns, or knives.
• Spending long periods of time alone.
• Giving away possessions.
• Acting mean and aggressive, or suddenly acting calm.

If a suicide threat seems real, with a specific plan and a way to carry it out, the following guidelines may help:

• Call 911 , a suicide hotline, or the police.
• Stay with the person, or ask someone you trust to stay with the person, until the crisis has passed.
• Encourage the person to seek professional help.
• Don't argue with the person ("It's not as bad as you think") or challenge him or her ("You're not the type to commit suicide").
• Tell the person you don't want him or her to die. Talk about the situation as openly as possible.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I stop taking my depression medicine?
	Should I take antidepressants while I'm pregnant?
	Should I take medications to treat depression?
	Actionsets are designed to help people take an active role in managing a health condition.
	Getting help for someone you think is depressed
	Managing postpartum depression
	Managing the side effects of antidepressants
	Supporting someone who has depression
	Taking antidepressants wisely
	Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.
	Interactive Tool: Are You Depressed?

Experts believe genetic traits, along with stressful events, illness, medications, or other factors, can lead to an imbalance of certain brain chemicals called neurotransmitters, causing depression. Conditions that may trigger depression include:

• Some medications, such as steroids or narcotics for pain relief. After the medication is stopped, the depressive symptoms usually disappear.
• Problems with hormones, such as imbalances in the thyroid or adrenal glands.
• Chemical imbalances, such as imbalances in blood calcium levels or low iron levels (anemia).
• Long-term (chronic) diseases, such as arthritis, heart disease, or cancer.
• Infections, such as viral infections or infections in the liver or brain.
• Social stressors, such as the death of a loved one.
• Chronic stressors, such as living in poverty, having family difficulties, or having serious medical problems or living with someone who does. Older adults who move from an independent lifestyle to one that is more dependent upon others often experience depression.
• Social and peer pressures in children and teens. For more information, see the topic Depression in Children and Teens.
• Drinking alcohol, using illegal drugs, or having a substance abuse problem.
• Other conditions, such as menopause or chronic pain, stress, or fatigue.
• Recent childbirth. For more information, see the topic Postpartum Depression.

If you have depression, you may feel hopeless and sad or stop feeling pleasure from almost everything you do. You may feel down in the dumps, tearful, or discouraged. You may also be irritable or anxious or have low energy levels. The symptoms of depression are often subtle at first. It can be hard to recognize that symptoms may be connected and that you might have depression.

The two most significant symptoms of depression are:³

• Sadness or hopelessness.
• Loss of interest in or pleasure from most daily activities.

Other symptoms include:³

• Losing or gaining weight because of changes in appetite.
• Sleeping too much or not enough.
• Feeling restless and unable to sit still, or feeling that moving takes a great effort.
• Feeling tired all the time.
• Feeling unworthy or guilty without an obvious reason.
• Having problems concentrating, remembering, or making decisions.
• Thinking often about death or suicide.

If you have at least five of these symptoms for 2 weeks or longer, and one of the symptoms is either sadness or loss of interest, you may be diagnosed with major depression that needs treatment. Even if you have fewer than five symptoms, you may still be depressed and need treatment.

If you have 2 to 4 symptoms for a period of at least 2 years (1 year for a child), you may have a long-term form of depression called dysthymic disorder (dysthymia).³

Many women experience mood changes before menstruation. Physical and emotional premenstrual symptoms that interfere with relationships or responsibilities are known as premenstrual syndrome (PMS). However, women who have emotional and physical premenstrual symptoms that seriously interfere with daily life may have a type of depression known as premenstrual dysphoric disorder (PMDD). For more information see the topic Premenstrual Syndrome (PMS).

Many health professionals see people with general symptoms that may be difficult to link to depression. These symptoms, which commonly occur with depression, include:

• Having headaches and other body aches and pains.
• Having digestive problems, including constipation or diarrhea.
• Losing interest in sex or being unable to perform sexually.
• Feeling anxious or worried without an obvious reason.
• Blaming yourself or others for your depression.
• Not moving or talking for hours.

Other symptoms of depression may include:^{4, 3}

• Overeating and weight gain (rather than loss of appetite).
• Oversleeping (rather than insomnia).
• Increased tearfulness, anger, and generally not feeling well, along with anxiety and tension.
• Sometimes, a feeling of heaviness in the arms and legs.
• Sensitivity to rejection.

Depression is a serious problem for people of any age, and older adults with symptoms of depression should seek treatment right away. Depression in older adults can cause confusion or forgetfulness (although some medications can cause these symptoms as well). Depression has also been identified as a significant risk factor for death in older adults with heart problems.⁵

It is important to recognize the early warning signs of depression so that you can get treatment. If you think you may have depression, take a short quiz to evaluate your symptoms:

Interactive Tool: Are You Depressed?

The symptoms of depression are often hard to notice at first. It can be hard to recognize that symptoms may be connected and that you might have depression. Symptoms of depression in children and teens are sometimes different from adult symptoms, which can make their depression more difficult to diagnose and treat. For more information, see the topic Depression in Children and Teens.

Depression can lead to suicide. The warning signs of suicide change with age.

• Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
• Warning signs of suicide in adults may include alcohol or substance abuse, recent job loss, or divorce.
• Warning signs of suicide in older adults may include the recent death of a partner or diagnosis of a life-limiting illness.

Depression may begin with symptoms of anxiety (such as excessive worrying) or symptoms such as sadness or lack of energy that last for days or months before the onset of full-blown depression. You may have trouble concentrating or remembering, experience a loss of pleasure in things you used to enjoy, feel hopeless, and have low energy and changes in sleeping and eating patterns. You may withdraw socially from others and lose interest in sexual activity.

The course of depression varies from one person to another. You might have mild or severe symptoms of depression for a long time, or you may have them for a brief time. A small number of people feel depressed for most of their lives and require ongoing treatment. Most people who have depression can be treated successfully with medication, professional counseling, or a combination of the two.

Depressive disorders are classified according to their severity and duration. Depression may be mild, moderate, or severe. It may start suddenly (acute) or be long-lasting (chronic). Dysthymic disorder, for example, is chronic mild depression. Some people may experience an episode of major depression on top of dysthymic disorder (double depression).

For severe depression, you may need to be admitted to a hospital for a short time, especially if you are having thoughts of suicide. Because depression puts you at a higher risk for attempting suicide, you should seek immediate treatment if you are having self-destructive thoughts.

Recurring illness

Depression often recurs. If you have one episode of depression, you are more likely to become depressed again at some point in your life than someone who has never been depressed. The risk of having another episode of depression increases with each additional episode.³

Related illness

Depressed people who have a chronic illness such as diabetes or coronary artery disease suffer more from symptoms of their illnesses, are less able to function, have a decreased quality of life, and pay more in medical costs. People with depression are less likely to take good care of themselves, and this may make their health worse.⁶

Sometimes episodes of depression are preceded or followed by periods of high energy (mania). If you cycle between depression and mania, you may have a condition called bipolar disorder. For more information, see the topic Bipolar Disorder.

If you have depression only during certain seasons of the year, such as the fall and winter months, you may have seasonal affective disorder. For more information, see the topic Seasonal Affective Disorder (SAD).

Several factors increase your risk for depression. Your risk of developing depression is up to three times greater than that of the general population if you have a father, mother, or sibling with depression. If you have had depression before, you are much more likely to have depression again.³

Other risk factors for depression include:

• A history of heart problems, such as coronary artery disease.
• A serious, ongoing (chronic) illness, such as diabetes, cancer, or chronic pain.
• Problems in your marriage.
• Use of drugs or alcohol.
• Use of certain medications that might trigger depression, such as steroids or narcotics for pain relief.
• A stressful life event, such as losing a job or the death of a loved one. This is especially true for older people who have many social stressors, such as becoming dependent upon others for care.
• Certain medical conditions, such as anemia and thyroid disease.
• Aging and dementia, a loss of mental skills that affects your daily life.
• Recent serious illness or surgery.
• A childhood history of physical or sexual abuse.
• Constantly worrying or being overly anxious.
• An eating disorder or anxiety disorder.

Additional risk factors for depression in women include:

• Recent childbirth. For more information, see the topic Postpartum Depression.
• Use of birth control pills (oral contraceptives). However, for some women, birth control pills can improve mood.
• A history of premenstrual dysphoric disorder (severe premenstrual syndrome, or PMS).

Call 911 or other emergency services if:

• You think you cannot keep from harming yourself or someone else.
• You hear voices.
• Someone you know attempts suicide, or shows warning signs of suicide, such as talking about suicide or harming someone else, showing signs of detachment from reality (psychosis), or is using alcohol or drugs excessively.

Depression can lead to suicide. The warning signs of suicide change with age.

• Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
• Warning signs of suicide in adults may include alcohol or substance abuse, recent job loss, or divorce.
• Warning signs of suicide in older adults may include the recent death of a partner or diagnosis of a life-limiting illness.

Watchful Waiting

Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. Watchful waiting may be appropriate if you have feelings of grief, sadness, or melancholy. However, if symptoms do not improve after 2 weeks, talk with a health professional.

Who To See

Treatment for depression usually involves taking medicine or getting professional counseling, or a combination of the two. It is important that you establish a long-term and comfortable relationship with your health professionals for treatment of depression.

Health professionals who can diagnose depression and prescribe medications include a:

• Family medicine physician.
• Internist.
• Psychiatrist.
• Physician assistant.
• Nurse practitioner.

Professional counseling can be provided by a:

• Psychiatrist (who can also diagnose and prescribe medications).
• Psychologist.

Other health professionals who also may be trained in counseling include:

• Social worker.
• Licensed professional counselor.
• Psychiatric nurse.

To prepare for your appointment, see the topic Making the Most of Your Appointment

If you think you have depression, your health professional will ask questions about your health. He or she may also order other tests such as:

• A thorough physical exam.
• Laboratory tests, to make certain your symptoms are not caused by something else, such as an underactive thyroid gland or anemia.
• A mental health assessment, which involves an interview with a health professional.
• Written or verbal tests that can detect depression.

Your health professional may ask questions to determine how severely depression might be affecting you, including whether you are having any suicidal thoughts.

If you have ever experienced a period of abnormal happiness, irritability, or intense energy that lasts 4 days or more, be sure to tell your health professional. Manic episodes, or milder hypomanic episodes, along with depression, could mean that you have bipolar disorder. Some types of antidepressant medications can make symptoms of bipolar disorder worse, so it is important to diagnose your symptoms accurately.

Anytime you visit your health professional, it is important to discuss any symptoms that may be caused by depression. About half of all cases of depression are undiagnosed or undertreated.² Health professionals are being encouraged to ask routine questions about depression at all office visits.

Initial treatment

Treatment of depression may include antidepressant medication, professional counseling such as cognitive-behavioral therapy, or a combination of the two.

• Professional counseling may be all that you need for mild to moderate depression.⁷
• If your early symptoms are severe, your initial treatment most likely will include both antidepressants and professional counseling.
• Hospitalization may be necessary if you show warning signs of suicide, such as thoughts or plans about harming yourself or another person, detachment from reality (psychosis), or excessive use of alcohol or drugs.

Depression can lead to suicide. The warning signs of suicide change with age.

• Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
• Warning signs of suicide in adults may include alcohol or substance abuse, recent job loss, or divorce.
• Warning signs of suicide in older adults may include the recent death of a partner or diagnosis of a life-limiting illness.

Depression usually can be successfully treated with medication, professional counseling, or a combination of the two. However, it sometimes takes several attempts to find the medication and type of counseling that work best for you. You may start to feel better within 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. If you have questions or concerns about your medicines, or if you do not notice any improvement by 3 weeks, talk to your doctor. You and your health professional will work together to find the right treatment.

If you think you may have depression, take a short quiz to evaluate your symptoms:

Interactive Tool: Are You Depressed?

Should I take medications to treat depression?

Should I take antidepressants during pregnancy?

If you have recently given birth, learning how to manage postpartum depression may help you recover more quickly.

How can I manage postpartum depression?

In rare cases, electroconvulsive therapy (ECT) may be an initial treatment choice for people who cannot take antidepressants, who have not responded to other treatments, or whose depression is severe and includes symptoms of psychosis, suicidal behavior, or an inability to eat.⁸ ECT involves an electric stimulation to the head which causes a brief seizure. This is thought to relieve depression by altering brain chemicals known as neurotransmitters.

Ongoing treatment

At least half of those who have one depression episode will have a recurrence of symptoms (relapse). Continuing to take antidepressant medicine after recovery reduces your risk of a relapse.⁹ Taking your medicine for at least 6 months after you feel better can help keep you from getting depressed again. If this is not the first time you have been depressed, your doctor may want you to take these medicines even longer.

Ongoing treatment for depression also includes:

• Eating a balanced diet.
• Avoiding alcohol.
• Getting exercise.
• Getting quality sleep.

It may also be helpful for you to obtain social support from family and friends.

If you have another illness along with depression, you need to continue treatment for your other illness. It is possible for other mood disorders such as anxiety and anxiety disorders, psychosis, or mania to accompany depression. For more information, see the topics Generalized Anxiety Disorder, Social Anxiety Disorder, and Bipolar Disorder.

Treatment if the condition gets worse

If your depression gets worse while you are receiving professional counseling alone, medication can be added to your treatment.

• Evidence shows that adding medications to counseling for severe depression works better than counseling alone.⁹
• If you have recurrent depression, you may need to take antidepressant medications for the rest of your life.

If your depression gets worse while you are already taking medications and receiving professional counseling, different or additional medications may be tried.

Electroconvulsive therapy (ECT) has been shown to be an effective treatment for severe depression or depression that has not been helped by other treatment.^{9, 8} ECT involves an electric stimulation to the head that causes a brief seizure. This is thought to relieve depression by altering brain chemicals known as neurotransmitters. ECT will need to be followed with medications and counseling, because relapse of symptoms is common.¹⁰

If your symptoms of depression get worse, it is essential to work with your health professional to find effective treatment. Major depression may be a risk factor for developing heart problems such as coronary artery disease or heart attack.¹¹ However, the greatest danger from depression is suicide. Up to 15% of people with depression die by suicide.³

The warning signs of suicide change with age.

• Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
• Warning signs of suicide in adults may include alcohol or substance abuse, recent job loss, or divorce.
• Warning signs of suicide in older adults may include the recent death of a partner or diagnosis of a life-limiting illness.

What To Think About

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed. The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.

Should I take antidepressants during pregnancy?

Anyone can develop depression regardless of age, race, or social status. As many as 1 out of every 10 people who visit a doctor has depression, but it goes unrecognized or undertreated in about half of those cases.² If left untreated, depression can lead to poor quality of life and higher risk of suicide.

Less than one-third of people with depression seek professional treatment.¹² Even when treatment is sought, health professionals sometimes attribute the vague symptoms of depression to other illnesses. You may not realize you are depressed, or you may be embarrassed to seek treatment. However, it is important to seek treatment as soon as you suspect that you or someone you love is depressed. The sooner you seek treatment, the better your chance for a quick and full recovery. Preventing recurrence of depression is also important.

If you need help deciding whether to see your doctor, see some reasons why people don't get help and how to overcome them.

Depression is not normal at any age, and treatment is important.

• Depression is often underdiagnosed in children and older adults. In children and adolescents, depression might be mistaken for hormonal "moodiness." For more information, see Depression in Children and Teens.
• Older adults may think it is normal to experience feelings of depression along with aging. Early treatment of depression in older adults can delay nursing home placement. The risk of death associated with depression increases significantly during the first year an older adult enters a nursing home.³

Family involvement and support in the treatment of depression can be very important, especially for children, teens, and older adults. Sometimes parents of depressed children and teens may also be diagnosed with depression and need treatment. Sometimes one or both parents can be depressed first and this can lead to their children also being diagnosed with depression.

If you have recently given birth, learning how to manage postpartum depression early on may help you recover more quickly and prevent a prolonged or serious problem with postpartum depression.

How can I manage postpartum depression?

Although you may not be able to prevent an initial bout of depression, you may be able to prevent a recurrence (relapse) or keep your symptoms from getting worse by:

• Taking your medications regularly as prescribed. Depression often returns if medications are stopped too early or are not taken as directed.
• Continuing to take medications after your symptoms improve. Taking your medicine for at least 6 months after you feel better can help keep you from getting depressed again. If this is not the first time you have been depressed, your doctor may want you to take these medicines even longer. ⁹
• Continuing with cognitive-behavioral therapy even after medications have been stopped. Research shows those who continued this type of counseling for 2 years after medications were stopped had lower rates of relapse.⁸
• Eating a balanced diet.
• Getting regular exercise.
• Seeking treatment immediately when you first notice new symptoms of depression—or symptoms that are getting worse—such as feelings of hopelessness or sadness or loss of interest or pleasure in most activities.
• Maintaining a regular sleep pattern.
• Avoiding drugs and alcohol.

It is difficult to prevent all recurrences of depression. However, you may be able to prevent or reduce the severity of future episodes. If you are on a maintenance dose of medication to treat ongoing depression, be sure to take all of your medications as directed by your health professional. Keep your counseling appointments. Seek help when you notice the first symptoms of depression, especially if your depressive episodes are moderate to severe.

Although therapy and antidepressant medication are the most effective treatments for depression, home treatment is also important. There are many steps you can take to help yourself during a depressive episode and to prevent future episodes:

• Set realistic goals for yourself, and take on a reasonable amount of responsibility.
• Break large tasks into small ones, and set priorities. Do what you can when you are able.
• Postpone major life decisions (such as changing jobs, moving, or getting married or divorced) when you are depressed.
• Try to share your feelings with someone. It is usually better than being alone and secretive.
• Let your family and friends help you.
• Even if you don't feel motivated, try to participate in religious, social, or other activities.
• Get regular exercise.
• Eat a balanced diet. If you lack an appetite, eat small snacks rather than large meals.
• Avoid drinking alcohol or using illegal drugs or medications that have not been prescribed to you. They may interfere with your medications or make your depression worse.
• Get adequate sleep. If you have problems sleeping:
  • Go to bed at the same time every night and, more importantly, get up at the same time every morning.
  • Keep your bedroom dark and free of noise.
  • Don't exercise after 5:00 p.m.
  • Avoid caffeinated beverages after 5:00 p.m.
  • Avoid the use of nonprescription sleeping pills or alcohol, because they can make your sleep restless and may interact with your depression medications.
• Be patient and kind to yourself. Remember that depression is not your fault and is not something you can overcome with willpower alone. Treatment is necessary for depression, just like for any other illness.
• Try to maintain a positive attitude—remember that feeling better takes time, and your mood will improve little by little.

Helping someone who is depressed

If you know someone who is depressed, it is important to be supportive and encouraging. If you have never experienced it, it is difficult to understand just how hopeless and discouraged depression can make you feel. Remember that depression can be as disabling as other major illnesses and can make it difficult to fulfill social, family, and work obligations. Like other illnesses, depression requires treatment, time, and patience.

Avoid offering advice, but encourage the person to seek and continue treatment. You do not need to take responsibility for the person's depression. However, if you notice any warning signs of suicide, such as talking about suicide or harming someone else, signs of detachment from reality (psychosis), or excessive use of alcohol or drugs, you should seek professional help immediately by calling the person's health professional. If you feel the person is in immediate danger, call 911 or other emergency services immediately.

For more information on helping someone with depression, see:

Getting help for someone you think is depressed.

Supporting someone who has depression.

Depression can lead to suicide. The warning signs of suicide change with age.

• Warning signs of suicide in children and teens may include preoccupation with death or suicide or a recent breakup of a relationship.
• Warning signs of suicide in adults may include alcohol or substance abuse, recent job loss, or divorce.
• Warning signs of suicide in older adults may include the recent death of a partner or diagnosis of a life-limiting illness.

Depression is often underdiagnosed and undertreated. Most depressed people need antidepressant medications. Antidepressants can improve or completely relieve the symptoms of depression.

Several medication options are available. There is no evidence that one medication works better than another; however, the side effects of the medications differ.⁹ You and your health professional can determine which medication is right for you.

You may start to feel better within 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. If you have questions or concerns about your medicines, or if you do not notice any improvement by 3 weeks, talk to your doctor.

Your doctor may prescribe an atypical antipsychotic, such as aripiprazole (Abilify), if your depression does not improve with antidepressants alone.

Medications affect your brain chemistry in different ways, so you may try several different medications or combinations of medications to find treatment that works for your depression. Most people find a drug that works within a few tries, but for some people, depression can be more difficult to treat. In some cases, a combination of antidepressants may be necessary. Sometimes an antidepressant combined with a different type of medication—such as an antiseizure, mood stabilizer, or antianxiety drug—is effective.

When taking antidepressant medication, it is important that you take the medication as prescribed. It may take several weeks before you notice the medication working. Side effects may improve after your body adjusts to the medication.

Taking your medicine for at least 6 months after you feel better can help keep you from getting depressed again. If this is not the first time you have been depressed, your doctor may want you to take these medicines even longer.

If you decide to quit taking antidepressants, it is important that you gradually reduce the dose over a period of several weeks. Quitting antidepressants abruptly can cause withdrawal symptoms. It is important to discuss quitting (or changing) medications with your health professional.

Should I stop taking my depression medicine?

Medication Choices

Antidepressant medications include:

• Selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Zoloft, or Paxil.
• Tricyclic and tetracyclic antidepressants, such as Elavil, Pamelor, or maprotiline.
• Atypical antidepressants, such as Wellbutrin, Effexor, or Remeron.
• Monoamine oxidase inhibitors (MAOIs), such as Nardil, Marplan, or Parnate.

What To Think About

If you and your health professional decide that you need medication, there are several considerations when choosing the right medication:

• Understand the side effects of the medication.
• Tell your health professional about all of your current medical conditions and all the medications you are taking, including nonprescription drugs, herbs, and supplements, so he or she can determine whether there are potential drug interactions.
• If you are an older person, you may need lower doses of medication, and it may take longer to be effective.
• Your health professional will need to monitor your progress to determine whether a particular medication is working for you.
• Often the first medication you take will effectively treat your depression. If not, there are other choices that will usually work well. You may need to try several different medications before you find the one that works best for you.
• Taking your medicine for at least 6 months after you feel better can help keep you from getting depressed again. If this is not the first time you have been depressed, your doctor may want you to take these medicines even longer. ⁹
• Some people need to remain on medication for several months to years (maintenance therapy). Others need medication for the remainder of their lives, especially those who have had several episodes of major depression.

When deciding which medication to prescribe, your health professional will consider:

• Your response to medications in previous depressive episodes.
• Whether you have other illnesses. Your doctor will want to make sure you are not given a depression medicine that will interact poorly with other medicines you are taking. He or she also may be able to prescribe depression medicine that benefits both your other illness and your depression.
• Whether the medication used to treat your depression will make any other illness you have worse or more difficult to treat.
• Your age and overall physical health. Older adults may need to take lower doses of medication for depression.
• How much the side effects of the medication are likely to bother you.

Should I take medications to treat depression?

Some people with depression do not continue taking their medications for depression or take them sporadically. It is important to continue taking medications for depression as prescribed, even after symptoms go away, to prevent recurrence of depression or to keep symptoms from getting worse. For more information see:

Taking antidepressants wisely

Side effects

You may start to feel better within 1 to 3 weeks of taking antidepressant medicine. But it can take as many as 6 to 8 weeks to see more improvement. During this time, you may experience side effects of the medicine. Many of the side effects are temporary and go away with continued use of the medicine, although some (such as dry mouth, constipation, and sexual problems) may continue. If you have questions or concerns about your medicines, or if you do not notice any improvement by 3 weeks, talk to your doctor.

• Do not stop taking the medication on your own unless you are having chest pain, hives, shortness of breath, trouble swallowing, or swelling of your lips. Contact your health professional immediately if you do experience any of these serious side effects.
• If your side effects are less serious but bothersome, talk with your health professional to see whether you should continue the medication or try another. There are many things you can do to reduce bothersome side effects of medications.

Antidepressant medications may need to be started at low doses and increased gradually, especially in most older adults. Medications should also be stopped gradually by decreasing the dose over a period of time. If certain antidepressant medications are stopped abruptly, you may suffer negative effects or the symptoms of depression may return.

Older adults or others who are depressed and taking several medications for other health conditions (not related to depression) need careful monitoring of their medications. People are more likely to have harmful side effects from taking many different medications.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed. The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.

Should I take antidepressants during pregnancy?

For more information about side effects, see:

Managing the side effects of antidepressants

The U.S. Food and Drug Administration has approved the vagus nerve stimulator (VNS) implant for treatment of depression. This device is used when other treatments for depression have not worked.

A generator the size of a pocket watch is placed in the chest. Wires go up the neck from the generator to the vagus nerve. The generator sends tiny electric shocks through the vagus nerve to that part of the brain that is believed to play a role in mood.

How well the VNS implant works has not been well studied and the device is expensive.¹³

Professional counseling is an important part of treatment for depression. Complementary therapies such as massage therapy and yoga may also help you recover more quickly and improve your quality of life. For information about relaxation techniques you can do at home, see relaxation exercises.

Family therapy may help you and those who care about you deal with depression.

Electroconvulsive therapy (ECT) may be used for those who cannot take antidepressant medications, who have not responded to other treatments, or whose depression is severe and includes symptoms of psychosis, suicidal behavior, or an inability to eat.⁸

Other Treatment Choices

Counseling is an important part of the treatment for depression. The types of counseling most often used for treatment of depression include:

• Cognitive-behavioral therapy, which teaches a person how to become healthier by modifying certain thought and behavior patterns. This type of therapy can be provided individually or in a group setting.
• Interpersonal therapy, which focuses on social and personal relationships and related problems.
• Problem-solving therapy, which focuses on the problems you are currently facing and on helping you find solutions to those problems.
• Family therapy, which involves the entire family.

Electroconvulsive therapy (ECT) may be used to treat severe depression or depression that has not responded well to medications and counseling. ECT also may be a treatment choice for someone who cannot tolerate the side effects of antidepressant medications. Modern ECT treatments consist of mild electric brain stimulation while you are unconscious (under general anesthetic) and are an effective treatment for depression. Side effects of ECT include memory loss and confusion.

Complementary therapies

• The herb St. John's wort has been shown to work for mild to moderate depression, but it can interact with other medications.
• Fish oil containing omega-3 fatty acids is currently being studied for possible antidepressant effects.
• SAM-e ( S-adenosylmethionine), a substance that occurs naturally in plant and animal cells, is sometimes used to treat depression. Some studies show SAM-e may help with symptoms of depression, but more studies are needed to determine its safety and effectiveness.

What To Think About

ECT

Deciding whether to try electroconvulsive therapy (ECT) can be difficult. Although ECT can be a very effective treatment for depression, you may experience short-term memory loss, confusion, nausea, headaches, and jaw pain for several hours—and sometimes even several days—after the procedure. For some people, ECT may cause long-term memory loss. For more information, see electroconvulsive therapy (ECT).

St. John's wort

St. John's wort is being tested in the United States to determine its safety and effectiveness. So far, the results have been mixed. Some negative and dangerous interactions between St. John's wort and certain medications have been discovered.⁹ Make sure your doctor has a complete list of all the medicines you are taking.

• Let your health professional know if you are using St. John's wort, especially if you are taking other medications.
• Avoid taking St. John's wort along with other antidepressants, because you could overmedicate yourself and have serious side effects.

Because St. John's wort is not currently regulated by the U.S. Food and Drug Administration (FDA), its quality—and effectiveness—may vary.

Omega-3 fatty acids

There is limited evidence that a small daily dose of omega-3 fatty acids may be beneficial either alone or when combined with an antidepressant.^{14, 15} Although benefits for depression are still inconclusive, research does show that taking omega-3 fatty acids can help fight other health problems, including arthritis and cardiovascular disease.

The American Heart Association (AHA) recommends eating fish at least twice per week, plus other omega-3 rich foods. For people with heart disease, the AHA suggests additional fish oil supplements if your health professional thinks it is a good idea.¹⁶

Book

Organizations

• Anorexia Nervosa
• Bipolar Disorder
• Depression in Children and Teens
• Generalized Anxiety Disorder
• Obsessive-Compulsive Disorder (OCD)
• Postpartum Depression
• Post-Traumatic Stress Disorder
• Premenstrual Syndrome (PMS)

Citations

1. Schulberg HC, et al. (1999). Best clinical practice: Guidelines for managing major depression in primary medical care. Journal of Clinical Psychiatry, 60(7): 19–28.

2. Whooley MA, Simon GE (2000). Managing depression in medical outpatients. New England Journal of Medicine, 343(26): 1942–1950.

3. American Psychiatric Association (2000). Depressive disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 349–381. Washington, DC: American Psychiatric Association.

4. Kornstein SG (2001). The evaluation and management of depression in women across the life span. Journal of Clinical Psychiatry, 62(Suppl 24): S11–S17.

5. Schulz R, et al. (2000). Association between depression and mortality in older adults: The cardiovascular health study. Archives of Internal Medicine, 160(12): 1761–1768.

6. Katon WJ (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54(3): 216–226.

7. Chilvers C, et al. (2001). Antidepressant drugs and generic counselling for treatment of major depression in primary care: Randomised trial with patient preference arms. BMJ, 322(7289): 772–775.

8. American Psychiatric Association (2000). Practice guidelines for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157(4, Suppl): S1–S45.

9. Butler R, et al. (2005). Depressive disorders, search date September 2004. Online version of Clinical Evidence (14): 1–41.

10. Sackeim HA, et al. (2001). Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy. JAMA, 285(10): 1299–1307.

11. Penninx BWJH, et al. (2001). Depression and cardiac mortality. Archives of General Psychiatry, 58(3): 221–227.

12. Davidson JRT, et al. (1999). The underrecognition and undertreatment of depression: What is the breadth and depth of the problem? Journal of Clinical Psychiatry, 60(Suppl 7): S4–S11.

13. Vagus nerve stimulation for depression (2005). Medical Letter on Drugs and Therapeutics, 47(1211): 50–51.

14. Peet M, Horrobin DF (2002). A dose-ranging study of the effects of ethyl-eicosapentaenoate in patients with ongoing depression despite apparently adequate treatment with standard drugs. Archives of General Psychiatry, 59(10): 913–919.

15. Keller JR (2002). Omega-3 fatty acids may be effective in the treatment of depression. Topics in Clinical Nutrition, 17(5): 21–27.

16. Covington MB (2004). Omega-3 fatty acids. American Family Physician, 70(1): 133-140.

Other Works Consulted

• Canadian Psychiatric Association and the CANMAT Depression Work Group (2001). Clinical practice guidelines for the treatment of depressive disorders. Canadian Journal of Psychiatry, 46(Suppl 1): S13–S89.

• Compton MT, Nemeroff CB (2006). Depression and bipolar disorder. In DC Dale, DD Federman, eds., ACP Medicine, section 13, chap. 2. New York: WebMD.

• Hypericum Depression Trial Study Group, American Medical Association (2002). Effect of hypericum perforatum (St. John's wort) in major depressive disorder. JAMA, 287(14): 1807–1814.

• Lam RW, et al. (2004). Prescribing antidepressants for depression in 2005: Recent concerns and recommendations. The Canadian Journal of Psychiatry, 49(12):1–6 (insert). Also available online: http://www.cpa-apc.org/Publications/Position_Papers/2004-23s-en.pdf.

• Murray MT, Bongiorno PB. (2006). Affective disorders. In JE Pizzorno Jr, MT Murray, eds. Textbook of Natural Medicine, 3rd ed., vol. 2, pp. 1427–1448. St. Louis: Churchill Livingstone Elsevier.

• Pignone MP, et al. (2002). Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 136(10): 765–776.

• Roose SP, et al. (2001). Relationship between depression and other medical illnesses. JAMA, 286(14): 1687–1690.

• Sadock BJ, Sadock VA (2003). Major depression and bipolar disorder. In Kaplan and Sadock's Synopsis of Psychiatry, 9th ed., ch. 15, pp. 534–590. Philadelphia: Lippincott Williams and Wilkins.

• Schatzberg AF, et al. (2002). Clinical use of nefazodone in major depression: A 6-year perspective. Journal of Clinical Psychiatry, 63(Suppl 1): S18–S31.

• Williams JW (2002). Is this patient clinically depressed? JAMA, 287(9): 1160–1170.

• Yager J, Gitlin MJ (2005). Depression section of Clinical manifestations of psychiatric disorders. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed., vol. 1, pp. 991–992. Philadelphia: Lippincott Williams and Wilkins.