Depression

What is depression?

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, and normal functioning, and causes pain for both the person with the disorder and those who care about them. Depression is a common but serious illness, and most who experience it require treatment to get better.

Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment. Intensive research into the illness has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling disorder.

What are the different forms of depression?

There are several forms of depressive disorders. The most common are:

1. Major depressive disorder
2. Dysthymic disorder
   

Some forms of depressive disorder exhibit slightly different characteristics than these, or they may develop under unique circumstances. However, not all scientists agree on how to characterise and define these forms of depression. They include:

• Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations and delusions.
• Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after having a baby. It is estimated that 10 to 15 per cent of women experience postpartum depression after giving birth.
• Seasonal affective disorder (SAD), which is characterised by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.
  
• Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterised by cycling mood changes from extreme highs (e.g., mania) to extreme lows (e.g., depression).

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What are the signs and symptoms of depression?

People with depressive illnesses do not all experience the same symptoms. The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness. Symptoms include:

• persistent sad, anxious or ‘empty’ feelings
• feelings of hopelessness and/or pessimism
• feelings of guilt, worthlessness and/or helplessness
• irritability, restlessness
• loss of interest in activities or hobbies once pleasurable, including sex
• fatigue and decreased energy
• difficulty concentrating, remembering details and making decisions
• insomnia, early-morning wakefulness or excessive sleeping
• overeating or appetite loss
• thoughts of suicide, or suicide attempts
• persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

What illnesses often co-exist with depression?

Depression often co-exists with other illnesses. Such illnesses may precede the depression, cause it, and/or be a consequence of it. It is likely that the mechanics behind the intersection of depression and other illnesses differ for every person and situation.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia and generalised anxiety disorder, often accompany depression. People experiencing PTSD are especially prone to having co-occurring depression. Alcohol and other substance abuse or dependence may also co-occur with depression.

Depression also often co-exists with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes and Parkinson’s disease. Studies have shown that people who have depression in addition to another serious medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical conditions, and more medical costs than those who do not have co-existing depression. Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co-occurring illness.

What causes depression?

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different to those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behaviour appear to function abnormally. In addition, important neurotransmitters – chemicals that brain cells use to communicate – appear to be out of balance. But these images do not reveal why the depression has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can also occur in people without family histories of depression. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.

In addition, trauma, loss of a loved one, a difficult relationship or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

How do women experience depression?

Depression is more common among women than among men. Biological, life cycle, hormonal and psychosocial factors unique to women may be linked to women’s higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the ‘baby blues’, but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression have often had prior depressive episodes.

Some women may also be susceptible to a severe form of premenstrual syndrome (PMS), sometimes called premenstrual dysphoric disorder (PMDD), a condition resulting from the hormonal changes that typically occur around ovulation and before menstruation begins. During the transition into menopause, some women experience an increased risk for depression. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.

Finally, many women face the additional stresses of work and home responsibilities, caring for children and ageing parents, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.

How do men experience depression?

Men often experience depression differently to how women experience it and may have different ways of coping with the symptoms. Men are more likely to acknowledge having fatigue, irritability, loss of interest in once-pleasurable activities, and sleep disturbances, whereas women are more likely to admit to feelings of sadness, worthlessness and/or excessive guilt.

Men are more likely than women to turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, irritable, angry and sometimes abusive. Some men throw themselves into their work to avoid talking about their depression with family or friends or engage in reckless, risky behaviour. And even though more women attempt suicide, many more men die by suicide.

How do older adults experience depression?

Depression is not a normal part of ageing, and studies show that most seniors feel satisfied with their lives, despite increased physical ailments. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and maybe less inclined to experience or acknowledge feelings of sadness or grief.

In addition, older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what some doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body’s organs, including the brain. Those with vascular depression may have, or be at risk for, a co-existing cardiovascular illness or stroke.

Although many people assume that the highest rates of suicide are among the young, in fact, older white males aged 85 and older actually have the highest suicide rate. Many have a depressive illness that their doctors may not detect, despite the fact that these suicide victims often visit their doctors within the month before their deaths.

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy or a combination of both. Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults. Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.

How do children and adolescents experience depression?

Scientists and doctors have begun to take seriously the risk of depression in children. Research has shown that childhood depression often persists, recurs and continues into adulthood, especially if it goes untreated. The presence of childhood depression also tends to be a predictor of more severe illnesses in adulthood.

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to diagnose a young person with depression accurately
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Before puberty, boys and girls are equally likely to develop depressive disorders. By age 15, however, girls are twice as likely as boys to have experienced a major depressive episode.

Depression in adolescence comes at a time of great personal change – when boys and girls are forming an identity distinct from their parents, grappling with gender issues and emerging sexuality, and making decisions for the first time in their lives. Depression in adolescence frequently co-occurs with other disorders such as anxiety, disruptive behaviour, eating disorders or substance abuse. It can also lead to increased risk for suicide.

Depression in South Africa

An epidemiological study of major depression in South Africa revealed that the prevalence of major depression was 9.7% for lifetime and 4.9% for the 12 months prior to the interview. The prevalence of depression was significantly higher among females than among males and higher among those with a low level of education. Over 90% of all respondents with depression reported global role impairment. This study reveals that South Africa has lower rates of depression than the USA but higher rates than Nigeria. 

Research has demonstrated the efficacy of CBT in the treatment of depression, with far superior success rates than placebo groups such as waiting-treatment groups. CBT is also an effective treatment when combined with antidepressant medication, with this combination generally being shown to be more effective than CBT or antidepressants alone.

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