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Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, or restless. They may lose interest in activities that once were pleasurable; experience loss of appetite or overeating, have problems concentrating, remembering details, or making decisions; and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may be present.

Depressed mood is not necessarily a psychiatric disorder. It is a normal reaction to certain life events, a symptom of some medical conditions, and a side effect of some medical treatments. Depressed mood is also a primary or associated feature of certain psychiatric syndromes such as clinical depression.

Life events
Life events that may precipitate depressed mood include personal conflicts or disputes with family members or friends, bereavement, moving, losing a job or income, divorce, retirement, menopause, social isolation, and social rejection.

Medical treatments
Certain medications are known to cause depressed mood in a significant number of patients. These include Hepatitis C drug therapy and some drugs used to treat high blood pressure, such as beta-blockers or reserpine.

Non-psychiatric illnesses
Depressed mood can be the result of a number of infectious diseases and physiological problems including hypogonadism (in men), Addison's disease, Lyme disease, multiple sclerosis, sleep apnea and disturbed circadian rhythm. It is often one of the early symptoms of hypothyroidism (reduced activity of the thyroid gland). For a discussion of non-psychiatric conditions that can cause depressed mood, see Depression (differential diagnoses).

Psychiatric syndromes
A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD), commonly called major depression or clinical depression, where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated energy levels, cognition and mood, but may also involve one or more depressive episodes.

Outside the mood disorders: borderline personality disorder commonly features depressed mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode, and posttraumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly accompanied by depressed mood.

Assessment
A full patient medical history, physical assessment, and thorough evaluation of symptoms helps determine the cause of the depression. Standardized questionnaires can be helpful such as the Hamilton Rating Scale for Depression, and the Beck Depression Inventory.

A doctor generally performs a medical examination and selected investigations to rule out other causes of symptoms. These include blood tests measuring TSH and thyroxine to exclude hypothyroidism; basic electrolytes and serum calcium to rule out a metabolic disturbance; and a full blood count including ESR to rule out a systemic infection or chronic disease. Adverse affective reactions to medications or alcohol misuse are often ruled out, as well. Testosterone levels may be evaluated to diagnose hypogonadism, a cause of depression in men. Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a dementing disorder, such as Alzheimer's disease. Cognitive testing and brain imaging can help distinguish depression from dementia. A CT scan can exclude brain pathology in those with psychotic, rapid-onset or otherwise unusual symptoms. No biological tests confirm major depression. Investigations are not generally repeated for a subsequent episode unless there is a medical indication.

Depression in Young Adults
Depression in young adults is a common health problem and a growing public concern. In 2006, 1 in 20 U.S. adults had experienced a major depressive episode with severe impairment. The Center for Disease Control and Prevention (CDC) reported that among ages 18-24, 2.8% met the criteria for major depression, 8.1% met the criteria for other depression (DSM-IV category Depressive Disorder, Not Otherwise Specified - minor or subthreshold depression, or Dysthymia) and 10.9% met the criteria for current depression. Forty-four percent of American college students report feeling symptoms of depression. This data suggests that traditional college aged students may be at high risk for depression or depressed mood.

Each year 44 colleges and universities use random sampling to administer the American College Health Association’s (ACHA) National College Health Assessment (NCHA) survey to 28,000 students. This assessment surveys students’ health status and behavior, including depression and depressive symptoms, for their previous academic year. Based on the findings, the rates of students reporting having been diagnosed with depression have increased from 10% in 2000 to 21% in 2011. In 2011, female students reported depressive symptoms, including 22% feeling that things were hopeless, 23% feeling lonely, and 26% feeling very sad within the preceding two weeks to 21% in 2011. Women are at higher risk than men to experience depression.

According to the American Psychological Association, three of the most common mental health problems that women experience are depression, eating disorders, and low self-esteem. In women, low self-esteem and negative thinking have been recognized as predictors for the development of depression. Low self-esteem contributes to depression in college women while high self-esteem shields against the development of depression. Peden and colleagues believe that by targeting negative thinking in college women depressive symptoms will be reduced.

Individuals with low self-esteem are more susceptible to depression because they do not have adequate coping skills, whereas those with high self-esteem are able to avoid depression because they have the skills to successfully cope. Ford discovered that when individuals with high self-esteem were compared to individuals with low self-esteem the high self-esteem individuals dealt with rejection better and recovered more quickly. The researcher’s findings show that low self-esteem may establish a weakness in physical well-being for individuals following rejection. Furthermore, when high self-esteem individuals are rejected they exhibit resilience.

Treatment
Treating depression (in the NHS, United Kingdom)

The National Health Service of the United Kingdom provides for the Treatment for depression through medicines, therapy and self-help.

Treatment overview

Wait and see

In cases of mild depression, there is a likelihood the depression may improve by itself - especially if there is no prior history of depression in the person or their family history. In this case the doctor may suggest simply seeing the patient again in two weeks to monitor their progress. This approach is known internally as 'watchful waiting'.

Exercise

Exercise has been proven to help depression, and is one of the main treatments if you have mild depression.

Your GP may refer you to a qualified fitness trainer for an exercise scheme or you can find out more about starting exercise here.

Self help groups

Talking through your feelings can be helpful. It can be either to a friend or relative, or you can ask your GP to suggest a local self-help group. Find out more about depression support groups. Your GP may also recommend self-help books and online cognitive behavioural therapy (CBT).

Talking therapy

If you have mild depression that isn't improving, or you have moderate depression, your GP may recommend a talking treatment. There are different types of talking therapy for depression including cognitive behavioural therapy (CBT) and counselling. Your GP can refer you for talking treatment or, in some parts of the country, you might be able to refer yourself. Read more below in Talking treatments.

Antidepressants

Antidepressants are tablets that treat the symptoms of depression. There are almost 30 different kinds of antidepressant They have to be prescribed by a doctor, usually for depression that is moderate or severe. Read more below in Antidepressants.

Combination therapy

Your GP may recommend that you take a course of antidepressants plus talking therapy, particularly if your depression is quite severe. A combination of an antidepressant and CBT usually works better than having just one of these treatments. Read more below in Antidepressants.

Mental health teams

If you have severe depression, you may be referred to a mental health team made up of psychologists, psychiatrists, specialist nurses and occupational therapists. These teams often provide intensive specialist talking treatments as well as prescribed medication.

Talking treatments

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) helps you understand your thoughts and behaviour and how they affect you.

CBT recognises that events in your past may have shaped you, but it concentrates mostly on how you can change the way you think, feel and behave in the present.

It teaches you how to overcome negative thoughts, for example being active to challenge feelings hopeless. CBT is available on the NHS for people with depression or any other mental health problem that it has been shown to help.

You normally have a short course of sessions, usually six to eight sessions, over 10-12 weeks on a one-to-one basis with a counsellor trained in CBT. In some cases, you may be offered group CBT. Read more about CBT.

Online CBT

Computerised CBT is a form of CBT that works through a computer screen, rather than face to face with a therapist.

It's delivered in a series of weekly sessions and should be supported by a healthcare professional. For instance, it's usually prescribed by your GP and you may have to use the surgery computer to access the programme.

Ask your GP for more information or read more about online CBT and the courses available here.

Interpersonal therapy (IPT)

IPT focuses on your relationships with other people and on problems you may be having in your relationships, such as difficulties with communication or coping with bereavement. There's some evidence that IPT can be as effective as antidepressants or CBT, but more research is needed.

Counselling

Counselling is a form of therapy that helps you think about the problems you are experiencing in your life to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but do not tell you what to do.

Counselling on the NHS usually consists of six to 12 hour-long sessions. You talk in confidence to a counsellor. The counsellor supports you and offers practical advice.

Counselling is ideal for people who are basically healthy but need help coping with a current crisis, such as anger, relationship issues, bereavement, redundancy, infertility or the onset of a serious illness.

Getting help

Your first port of call should be your GP, who can refer you for NHS talking treatments for depression available locally. In some parts of the country, you also have the option of self-referral. This means that if you prefer not to talk to your GP you can go directly to a professional therapist.

Antidepressants

Antidepressants are medicines that treat the symptoms of depression. There are almost 30 different kinds of antidepressant available.

Most people with moderate or severe depression benefit from antidepressants, but not everybody does. You may respond to one antidepressant, but not to another, and you may need to try two or more treatments before you find one that works for you.

The different types of antidepressant work about as well as each other. However, side effects vary between different treatments and people.

When you start taking antidepressants you should see your GP or specialist nurse every week or two for at least four weeks to see how well they are working. If they are working, you'll need to continue taking them at the same dose for at least four to six months after your symptoms have eased.

If you've had bouts of depression in the past, you may need to continue to take antidepressants for up to five years or longer.

Antidepressants aren't addictive, but be prepared to get some withdrawal symptoms if you stop taking them suddenly or you miss a dose.

Selective serotonin reuptake inhibitors (SSRIs)

If your GP thinks you would benefit from taking an antidepressant, you'll usually be prescribed a modern type called a selective serotonin reuptake inhibitor (SSRI). Examples of commonly used SSRI antidepressants are Seroxat (paroxetine), Prozac (fluoxetine) and Cipramil (citalopram).

They help increase the level of a natural chemical in your brain called serotonin, which is thought to be a ‘good mood’ chemical.

SSRIs work just as well as older antidepressants and have fewer side effects.

They can, however, cause nausea and headaches, as well as dry mouth and problems having sex. However, all these negative effects usually improve over time.

Some SSRIs aren't suitable for children under the age of 18. Research shows that the risk of self-harm and suicidal behaviour may increase if they're taken by under-18s. Fluoxetine is the only SSRI that can be prescribed for under-18s, and even then only when a specialist has given the go-ahead.

Tricyclic antidepressants (TCAs)

This group of antidepressants is used to treat moderate to severe depression.

TCAs, which includes Dosulepin (dothiepin), Imipramil (imipramine) and amitriptyline, have been around for longer than SSRIs.

They work by raising the levels of the chemicals serotonin and noradrenaline in your brain. These both help lift your mood.

They're generally quite safe, but it's a bad idea to smoke cannabis if you are taking TCAs because it can cause your heart to beat rapidly.

Side effects of TCAs, which vary from person to person, may include dry mouth, blurred vision, constipation, problems passing urine, sweating, light-headedness and excessive drowsiness.

The side effects usually ease after 7 to 10 days, as your body gets used to the medication.

Monoamine oxidase inhibitors (MAOIs)

MAOIs, such as Nardine (phenelzine sulphate) are sometimes used to treat depression.

If you are taking MAOIs, you need to avoid food that contains the chemical tyramine, such as cheese, pickled meat or fish. Your GP will give you a more detailed list of food and drink to avoid.

You should also avoid drinking any alcohol or fermented liquids (even if they are alcohol free). Steer clear of smoking cannabis if you are taking MAOIs because it may affect the way these medicines work, and it's not clear what effect it may have on you.

Common side effects of MAOIs include blurred vision, dizziness, drowsiness, increased appetite, nausea, restlessness, shaking or trembling, and difficulty sleeping.

The dietary restrictions and potential for side effects mean that MAOIs are used very rarely, and are normally only prescribed when other treatments have not been effective. Other antidepressants

New antidepressants, such as Effexor (venlafaxine) and Zispin Soltab (mirtazapine), work in a slightly different way from SSRIs and TCAs.

These drugs are known as SNRIs (serotonin-norepinephrine reuptake inhibitors). Like TCAs, they change the levels of serotonin and noradrenaline in your brain. Studies have shown that an SNRI can be more effective than an SSRI, though they're not routinely prescribed as they can lead to a rise in blood pressure. Withdrawal symptoms Antidepressants are not addictive in the same way that illegal drugs and cigarettes are, but when you stop taking them you may have some withdrawal symptoms, including: - upset stomach - flu-like symptoms - anxiety - dizziness - vivid dreams at night - sensations in the body that feel like electric shocks

In most cases these are quite mild, but occasionally they can be quite severe. They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Effexor).

Other treatments

St John's wort

St John's wort is a herbal treatment that some people take for depression. It's available from health food shops and pharmacies. There's some evidence that it may help mild to moderate depression, but it's not recommended by doctors. This is because the amount of active ingredients varies among individual brands and batches, so you can never be sure what sort of effect it will have on you.

Taking St John's wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems. You shouldn't take St John's wort if you are pregnant or breastfeeding, as we don't know for sure that it's safe.

Electric shock treatment

Sometimes electroconvulsive therapy (ECT) may be recommended if you have severe depression and other treatments including antidepressants haven't worked. During ECT, you'll first be given an anaesthetic and medication to relax your muscles. Then you'll receive an electrical 'shock' to your brain through electrodes placed on your head. You may be given a series of ECT sessions. It is usually given twice a week for 3-6 weeks. For most people, ECT is good for relieving severe depression, but the beneficial effect tends to wear off after several months. Some people get unpleasant side effects, including short-term headaches, memory problems, nausea and muscle aches.

Lithium

If you've tried several different antidepressants and had no improvement, your doctor may offer you a type of medication called lithium, in addition to your current treatment. There are two types of lithium: lithium carbonate and lithium citrate. Both are usually effective, but if you are taking one that works for you, it's best not to change. If this level of lithium in your blood becomes too high, it can become toxic. So, you'll need blood tests every three months to check your lithium levels while you're on it. You'll also need to avoid eating a low-salt diet because this can also cause the lithium to become toxic. Ask your GP for advice about your diet.