National Alliance on Mental Illness
■What Is Major Depression?
Major depression is a mood state that goes well beyond
temporarily feeling sad or blue. It is a serious medical illness that
affects one’s thoughts, feelings, behavior, mood, and physical health.
Major depression can occur at any age, even in rare cases
starting as young as preschool. Some individuals may only have
one episode of depression in a lifetime, but more often people
have recurrent episodes. More than half of those who experience
a first episode of depression will have at least one other episode
in their lives. Some people may have several episodes in the course
of a year, and others may have ongoing symptoms. If untreated,
episodes commonly last anywhere from a few months to
many years.
The outward behavior of the person with depression often
does not attract attention. The behavior of the depressed
individual, although quite worrisome to family members and
friends and even to him- or herself, rarely disrupts the lives of
others to the extent that some other serious mental illnesses do.
However, major depression is disruptive in other ways, by
causing people to withdraw from their relationships, from their
work, and from the very fabric of society. In fact, major depression
ranks as the largest cause of disability in the developed world, and
the fourth-largest cause of disability in the developing world.
To make matters worse, researchers believe that more than half
of people who succeed in committing suicide were suffering from
depression at the time.
The normal human emotion we sometimes call “depression” is
a common response to a loss, failure, or disappointment. Major
depression is different. It is a serious emotional and biological
disease, which—with a correct diagnosis—can typically be treated
effectively. Major depression may require long-term treatment to
keep symptoms from returning, just like any other chronic medical
illness. For some, biological depression is a life-long condition in
which periods of wellness alternate with recurrences of illness.
The use of alcohol, a central nervous system depressant, can be
a serious complication for depressed individuals who use it to try
to change how they feel. All alcohol should be avoided during
treatment for depression for several reasons. First, after its initial
anti-anxiety effect, alcohol produces increased feelings of depres-
sion. Regular alcohol alone can cause a depressed mood that lasts
for weeks, even after the use of alcohol stops. Second, in combina-
tion with many antidepressants, alcohol can make drug side effects
much worse, even dangerously so, and may make antidepressants
less effective. Third, alcohol reduces inhibitions, which increases
the risk of suicide or suicidal gestures.
Getting an accurate diagnosis is important. First, rule out
other possible medical conditions that mimic depression—such
as hypothyroidism (too little thyroid), substance abuse, infectious
processes, anemia, and neurological disorders.
What Are the Symptoms?
The onset of the first episode of major depression may not
be obvious, if it is brief or mild. Unrecognized or left untreated,
however, it may recur with greater seriousness or progress to
a syndrome with the following symptoms: a profoundly sad or
irritable mood lasting at least two weeks, and accompanied by
pronounced changes in sleep, appetite, energy, ability to
concentrate and remember, a lack of interest in usual activities,
and a decreased ability to experience pleasure. Frequently, there are feelings of hopelessness, worthlessness, sadness,
emptiness, or guilt. Very depressed persons cannot respond
to positive events in their lives. A depressive episode may
develop gradually or affect a person quite suddenly, and it
frequently is unrelated to current events in the person’s life.
The symptoms of clinical depression characteristically
represent a significant change in how a person functions.
Often, when all of those symptoms co-exist at a severe
level for a long time, individuals become so discouraged and
hopeless that death seems preferable to life. These feelings
can lead to passive suicidal wishes, suicidal plans, and even
attempted and completed suicide.
Changes in sleep:The changes in sleep can go in either
direction. Some depressed individuals have difficulty falling
asleep, wake throughout the night, and awaken an hour to
several hours earlier than desired in the morning. Other
individuals experiencing depression will sleep more than
the usual amount. In most cases, individuals awaken
without feeling rested.
Changes in appetite: Many people in a clinical depression
experience a decrease in appetite and weight loss that can
often be considerable. Others will experience an increased
desire to eat and will gain weight. Most of these people will
report that the food they are eating does not actually
appeal to them.
Impaired concentration and decision making:The inability
to concentrate and make decisions experienced by depressed
individuals can be a frightening aspect of the disorder. In the
midst of a severe depression, individuals may find that they
cannot follow the thread of a simple newspaper article or
the story line of a half-hour comedy on television. Major deci-
sion making is often impossible. This often leads depressed
individuals to feel as though they are literally losing their minds.
Loss of energy:Equally distressing to depressed persons
is the loss of energy and profound fatigue experienced by
both those who sleep more and those who sleep less during
an episode. Mental speed and activity are usually reduced, as
is the ability to perform normal daily routines. Ideas are fewer,
and responses to the environment are painfully slowed.
Loss of interest: Depressed people feel sad and lose
interest in their usual activities. They lose their capacity to
experience pleasure. For instance, eating and sex are often
no longer enjoyable. Former regular activities seem boring
or unrewarding, and the ability to feel and offer love may
be diminished or lost.
Low self-esteem biggrin uring periods of depression, individuals
often dwell on memories of losses or failures, and they feel
excessive guilt and helplessness. Negative thoughts, such as
“I am not worth much” or “the world is a terrible place,”
may take over.
Feelings of hopelessness or guilt: The symptoms of depression
often come together to produce a strong feeling of hopelessness,
a belief that nothing will ever improve. Periods of depression
can lead to the wish to die or thoughts of killing oneself.
Movement changes razz eople who are depressed may literally
look slowed down—physically depleted—or alternatively, activated
and agitated. For example, a depressed person may awaken very
early in the morning and pace the floor for hours.
Depression may be as disabling, in terms of time spent in
bed and loss of work productivity, as other chronic illnesses, like
hypertension and diabetes. It has been estimated that the annual
cost of depressive illness in the United States is $80 billion, due
to lost productivity and to illness care.
■What Causes Major Depression?
The general scientific understanding is that depression does
not have a single cause; it arises from multiple factors that
may need to occur simultaneously. A person’s life experience,
genetic inheritance, age, sex, brain chemistry imbalance, hormone
changes, substance use, and other illnesses all play significant
roles in the development of a depression. It also may occur that
there is no observable trigger leading to the illness; depression
may occur spontaneously and be unassociated with any life
crisis, physical illness, or other currently known risks.
Mood disorders and suicides tend to run in families. In
the case of complete biologic inheritance, such as with identical
twins, it appears that only about 30 percent of the time when
one twin develops depression will the other twin ever do so as
well. We know that a biologically inherited tendency to develop
depression is associated with a younger age of depression onset,
and that new onset depression occurring after age 60 is less
likely to be due to a genetic predisposition. Life factors and
events seem to influence whether an inherited, biologic
(genetic) tendency to develop depression will ever lead
to an episode of major depression.
Social variables like marital status, financial standing, and
place of residence have some relationship to the likelihood
of developing depression, but conclusions are not easily reached as to which causes the other. For instance, though depression
is more common in people who are homeless, it may be that the
depression strongly influences why any given person becomes
homeless. We also know that long-lasting stressors like
unemployment or a difficult marriage play a more significant
role in developing depression than sudden stressors like an
argument or receiving bad news.
Traumatic experiences may not only contribute to one’s general
state of stress, but also seem to alter how the brain functions for
years to come. Early-life traumatic experiences have been shown
to cause long-term changes in how the brain responds to future
fears and stresses. It is felt that this may be what accounts for
the greater lifetime incidence of major depression in people
who have a history of significant childhood trauma.
Other proposed biologic pathways in the development of
depression include changes observed in regional brain functioning.
For instance, imaging studies have shown consistently that the left,
front portion of the brain becomes less active during depression.
Also, brain patterns during sleep change in a characteristic way
during depression. Depression is also associated with changes
in how the pituitary gland and hypothalamus respond to
hormone stimulation.
Other factors that have been linked to depression
include abnormalities in neurotransmitter levels or function
(particularly of serotonin, norepinephrine, and dopamine),
a history of sleep disturbances, medical illness, chronic pain,
anxiety, attention-deficit hyperactivity disorder, alcoholism, or
drug abuse. Our current understanding is that major depression
can have many causes and can develop from a variety of
biologic pathways.
Major depression is a mood state that goes well beyond
temporarily feeling sad or blue. It is a serious medical illness that
affects one’s thoughts, feelings, behavior, mood, and physical health.
Major depression can occur at any age, even in rare cases
starting as young as preschool. Some individuals may only have
one episode of depression in a lifetime, but more often people
have recurrent episodes. More than half of those who experience
a first episode of depression will have at least one other episode
in their lives. Some people may have several episodes in the course
of a year, and others may have ongoing symptoms. If untreated,
episodes commonly last anywhere from a few months to
many years.
The outward behavior of the person with depression often
does not attract attention. The behavior of the depressed
individual, although quite worrisome to family members and
friends and even to him- or herself, rarely disrupts the lives of
others to the extent that some other serious mental illnesses do.
However, major depression is disruptive in other ways, by
causing people to withdraw from their relationships, from their
work, and from the very fabric of society. In fact, major depression
ranks as the largest cause of disability in the developed world, and
the fourth-largest cause of disability in the developing world.
To make matters worse, researchers believe that more than half
of people who succeed in committing suicide were suffering from
depression at the time.
The normal human emotion we sometimes call “depression” is
a common response to a loss, failure, or disappointment. Major
depression is different. It is a serious emotional and biological
disease, which—with a correct diagnosis—can typically be treated
effectively. Major depression may require long-term treatment to
keep symptoms from returning, just like any other chronic medical
illness. For some, biological depression is a life-long condition in
which periods of wellness alternate with recurrences of illness.
The use of alcohol, a central nervous system depressant, can be
a serious complication for depressed individuals who use it to try
to change how they feel. All alcohol should be avoided during
treatment for depression for several reasons. First, after its initial
anti-anxiety effect, alcohol produces increased feelings of depres-
sion. Regular alcohol alone can cause a depressed mood that lasts
for weeks, even after the use of alcohol stops. Second, in combina-
tion with many antidepressants, alcohol can make drug side effects
much worse, even dangerously so, and may make antidepressants
less effective. Third, alcohol reduces inhibitions, which increases
the risk of suicide or suicidal gestures.
Getting an accurate diagnosis is important. First, rule out
other possible medical conditions that mimic depression—such
as hypothyroidism (too little thyroid), substance abuse, infectious
processes, anemia, and neurological disorders.
What Are the Symptoms?
The onset of the first episode of major depression may not
be obvious, if it is brief or mild. Unrecognized or left untreated,
however, it may recur with greater seriousness or progress to
a syndrome with the following symptoms: a profoundly sad or
irritable mood lasting at least two weeks, and accompanied by
pronounced changes in sleep, appetite, energy, ability to
concentrate and remember, a lack of interest in usual activities,
and a decreased ability to experience pleasure. Frequently, there are feelings of hopelessness, worthlessness, sadness,
emptiness, or guilt. Very depressed persons cannot respond
to positive events in their lives. A depressive episode may
develop gradually or affect a person quite suddenly, and it
frequently is unrelated to current events in the person’s life.
The symptoms of clinical depression characteristically
represent a significant change in how a person functions.
Often, when all of those symptoms co-exist at a severe
level for a long time, individuals become so discouraged and
hopeless that death seems preferable to life. These feelings
can lead to passive suicidal wishes, suicidal plans, and even
attempted and completed suicide.
Changes in sleep:The changes in sleep can go in either
direction. Some depressed individuals have difficulty falling
asleep, wake throughout the night, and awaken an hour to
several hours earlier than desired in the morning. Other
individuals experiencing depression will sleep more than
the usual amount. In most cases, individuals awaken
without feeling rested.
Changes in appetite: Many people in a clinical depression
experience a decrease in appetite and weight loss that can
often be considerable. Others will experience an increased
desire to eat and will gain weight. Most of these people will
report that the food they are eating does not actually
appeal to them.
Impaired concentration and decision making:The inability
to concentrate and make decisions experienced by depressed
individuals can be a frightening aspect of the disorder. In the
midst of a severe depression, individuals may find that they
cannot follow the thread of a simple newspaper article or
the story line of a half-hour comedy on television. Major deci-
sion making is often impossible. This often leads depressed
individuals to feel as though they are literally losing their minds.
Loss of energy:Equally distressing to depressed persons
is the loss of energy and profound fatigue experienced by
both those who sleep more and those who sleep less during
an episode. Mental speed and activity are usually reduced, as
is the ability to perform normal daily routines. Ideas are fewer,
and responses to the environment are painfully slowed.
Loss of interest: Depressed people feel sad and lose
interest in their usual activities. They lose their capacity to
experience pleasure. For instance, eating and sex are often
no longer enjoyable. Former regular activities seem boring
or unrewarding, and the ability to feel and offer love may
be diminished or lost.
Low self-esteem biggrin uring periods of depression, individuals
often dwell on memories of losses or failures, and they feel
excessive guilt and helplessness. Negative thoughts, such as
“I am not worth much” or “the world is a terrible place,”
may take over.
Feelings of hopelessness or guilt: The symptoms of depression
often come together to produce a strong feeling of hopelessness,
a belief that nothing will ever improve. Periods of depression
can lead to the wish to die or thoughts of killing oneself.
Movement changes razz eople who are depressed may literally
look slowed down—physically depleted—or alternatively, activated
and agitated. For example, a depressed person may awaken very
early in the morning and pace the floor for hours.
Depression may be as disabling, in terms of time spent in
bed and loss of work productivity, as other chronic illnesses, like
hypertension and diabetes. It has been estimated that the annual
cost of depressive illness in the United States is $80 billion, due
to lost productivity and to illness care.
■What Causes Major Depression?
The general scientific understanding is that depression does
not have a single cause; it arises from multiple factors that
may need to occur simultaneously. A person’s life experience,
genetic inheritance, age, sex, brain chemistry imbalance, hormone
changes, substance use, and other illnesses all play significant
roles in the development of a depression. It also may occur that
there is no observable trigger leading to the illness; depression
may occur spontaneously and be unassociated with any life
crisis, physical illness, or other currently known risks.
Mood disorders and suicides tend to run in families. In
the case of complete biologic inheritance, such as with identical
twins, it appears that only about 30 percent of the time when
one twin develops depression will the other twin ever do so as
well. We know that a biologically inherited tendency to develop
depression is associated with a younger age of depression onset,
and that new onset depression occurring after age 60 is less
likely to be due to a genetic predisposition. Life factors and
events seem to influence whether an inherited, biologic
(genetic) tendency to develop depression will ever lead
to an episode of major depression.
Social variables like marital status, financial standing, and
place of residence have some relationship to the likelihood
of developing depression, but conclusions are not easily reached as to which causes the other. For instance, though depression
is more common in people who are homeless, it may be that the
depression strongly influences why any given person becomes
homeless. We also know that long-lasting stressors like
unemployment or a difficult marriage play a more significant
role in developing depression than sudden stressors like an
argument or receiving bad news.
Traumatic experiences may not only contribute to one’s general
state of stress, but also seem to alter how the brain functions for
years to come. Early-life traumatic experiences have been shown
to cause long-term changes in how the brain responds to future
fears and stresses. It is felt that this may be what accounts for
the greater lifetime incidence of major depression in people
who have a history of significant childhood trauma.
Other proposed biologic pathways in the development of
depression include changes observed in regional brain functioning.
For instance, imaging studies have shown consistently that the left,
front portion of the brain becomes less active during depression.
Also, brain patterns during sleep change in a characteristic way
during depression. Depression is also associated with changes
in how the pituitary gland and hypothalamus respond to
hormone stimulation.
Other factors that have been linked to depression
include abnormalities in neurotransmitter levels or function
(particularly of serotonin, norepinephrine, and dopamine),
a history of sleep disturbances, medical illness, chronic pain,
anxiety, attention-deficit hyperactivity disorder, alcoholism, or
drug abuse. Our current understanding is that major depression
can have many causes and can develop from a variety of
biologic pathways.
