Depression is a very common illness that can affect anyone, male or female, of any age and at almost any time. It's more than feeling blue or down in the dumps for a few days. Depression is a longer-lasting condition that can, in many cases, completely dominate daily life.

\What are the main symptoms?

We all feel a little low from time to time, but a persistent "down" feeling could be a sign of depression.

The symptoms of depression can be both psychological and physical. If you are experiencing five or more of the following symptoms, you may be suffering from depression.

  • A persistent feeling of sadness or unhappiness, which is often worse at a particular time of day, especially early in the morning.
  • Loss of interest and/or pleasure in life.
  • Inappropriate feelings of guilt – blaming yourself things for that have nothing to do with you.
  • Feeling worthless.
  • Difficulties with memory and concentration.
  • Loss of appetite.
  • Significant, unplanned weight loss.
  • Sleeping difficulties – either problems in dropping off, or waking early and being unable to get back to sleep.
  • Thoughts or plans of suicide.

There are also various specific types of depression, including manic depression, seasonal affective disorder and post-natal depression (yes, men can be affected by that too).

What's the risk?

Depression is often called "the common cold of psychiatry" precisely because it is so commonplace. Up to 20% of the population can expect to suffer from a major, disabling bout of depression during their lifetime and, at any one time, one in twenty of us is suffering from depression.

Traditionally there has been a marked gender imbalance in depression, with three times as many women as men suffering from the condition.

What causes it?

Depression is a complex disorder, with many different risk factors.

  • Genetics. Mood disorders, which is the psychiatric term for depression and manic depression, do tend to run in families. It looks as if many different genes are involved in depression, so the pattern of inheritance is complex. However, if you have a first-degree relative (i.e. a parent or sibling) with depression, you have between one-and-a-half and three times the chance of developing the condition yourself compared with the general population. And the younger the age of onset in your relative, the stronger the genetic influence could be in your case. In manic depression the genetic factor is more pronounced. People with a first-degree relative with the disorder are ten times more likely than average to develop the condition themselves.
  • Childhood factors. It may seem surprising, but it's been hard to make definite links between a disadvantaged childhood and adult depression. However, a feeling of helplessness learned in childhood, perhaps because of poor parenting, could well be linked to negative thinking in later life.
  • Stress and illness. Stress sets the scene for both depression and physical illness. If you ask depressed people about the stressful life events that preceded their illness, they report more than the average number. It's estimated that around 5% of all clinical depression can be attributed to physical illness.
  • Around a quarter of those with heart disease, diabetes, and cancer develop depression. Sometimes this is linked to prescribed treatments.
  • 10% of those with AIDS, and people on kidney dialysis, become depressed too.
  • Neurological illnesses such as Alzheimer's disease and multiple sclerosis are strongly associated with depression too. In fact, depression often mimics Alzheimer's disease and it is very important to distinguish the two in an older man who is forgetful and withdrawn. Alzheimer's is not curable (although it can be treated) whereas depression is.
  • Social and psychological factors. Many men are concerned with being competitive, powerful and successful. Increasing male unemployment and the rising presence of women in the workplace has tended to erode male status. This could have contributed to the increase in depression among men.
  • Most divorces and separations are initiated by women, and their male partners suffer the pain of separation and abandonment. In fact, divorced men are more likely than any other group to kill themselves, with social isolation being a major factor.
  • The fact that men often "drown their sorrows" in alcohol rather than talking about their problems more openly is another factor contributing to male depression.

How can I prevent it?

Depression sometimes strikes out of the blue and it's hard to see how you could prevent it. But depression is often a chronic disease – once you have had one attack the chances of recurrence are as high as 60%. After two episodes, the chances of suffering a third one are around 70%. And after this a chronic course may result, especially if untreated.

So, prevention starts once you have had one attack of depression. If you're recommended long-term treatment with antidepressant drugs it is a good idea to try to comply, as you would with treatment for diabetes or high blood pressure.

You should also be alert to the early signs of depression, which, according to the latest research, may include problems with memory and concentration.

Should I see a psychologist?

  • You should always seek professional help if you have five or more of the symptoms of depression described above, particularly if they have persisted for two weeks or more.
  • However, depression is a greatly under-recognised problem – both on the part of patients and health professionals.
    • First, depression is hard to recognise for the person in its grip.
    • And then, since lack of energy and a feeling of worthlessness are often hallmarks of depression, there may be difficulties in motivating yourself to seek help, or even feeling you deserve it.
  • Men, in particular, could feel awkward in approaching a health professional with symptoms of depression. They may feel that it's weak and unmanly to admit to feelings of despair. It can feel easier to admit to physical symptoms rather than emotional symptoms.
  • You can help get a correct diagnosis by being very clear about all your symptoms – psychological, as well as physical. Although psychologists will regularly see cases of depression, you cannot expect them to read your mind.
  • Your doctor can refer you to a psychologist, but this is unusual. You are more likely to be prescribed antidepressant medication. You can ask your doctor for a referral to a psychologist if you suffer from depression, you are not responding to antitreatment, or have complicating factors such as alcohol or drug abuse.

What are the main treatments?

The mainstay of treatment for depression is antidepressant drugs. These are effective in two-thirds of people with moderate or severe depression. Contrary to popular belief, these are not addictive (unlike tranquillisers, which were formerly used to treat depressive states).

A drawback of most antidepressants is that although they begin to work almost immediately, the effects are not usually felt for two or three weeks and it may take up to six weeks before the benefits kick in, requiring a certain level of commitment from people taking them.

Antidepressants fall into several different drug categories:

  • Tricyclics. These are the older generation of antidepressants, and they work by raising the levels of noradrenaline and serotonin – brain chemicals which are thought to be depleted in depression. They have side-effects such as a dry mouth, weight gain and dizziness, although newer drugs in the tricyclic class give patients fewer problems. Examples of tricyclics include imipramine (Tofranil) and nortriptyline (Allegron).
  • Specific serotonin reuptake inhibitors (SSRIs). The primary example of this group, which acts just on the serotonin pathways in the brain, is fluoxetine (Prozac). There has been a lot of interest in SSRIs over the last decade because they are relatively free of side-effects – they can therefore be prescribed to people with mild forms of depression.
    Prozac is the best known SSRI but it's not the only one. Finding the best SSRI in any particular case may take some trial and error. Other examples include:
    • citalopram (Cipramil)
    • paroxetine (Seroxat)
    • fluvoxamine (Faverin)
    • sertraline (Lustral)
  • Monoamine oxidase inhibitors (MAOIs). These are older drugs, which have been associated with severe – even fatal – side-effects if some foods are eaten (red wine and cheese are the main culprits). But a new MAOI, moclobemide (Manerix), has minimal side-effects and works well in depression.
  • Noradrenaline reuptake inhibitors (NARIs). Like the SSRIs, these work on just one brain chemical, in this case noradrenaline. Reboxetine (Edronax), the main example of this class to date, is said to improve social functioning in withdrawn patients – a must when it comes to preserving jobs and relationships.
  • Noradrenaline and serotonin specific uptake inhibitors (NASSAs). The ultimate designer drugs for depression so far, NASSAs act on both of the brain chemical systems involved in depression, while minimising the side-effects. The main example to date is mirtazapine (Zispin).
  • Another drug which doesn't really fit into any of these categories is venlafaxine (Efexor) - put simply, its action on the brain is somewhere between that of a tricyclic and an SSRI.

However, antidepressant drugs alone are not really sufficient to cure a bout of depression and prevent its recurrence. Ideally your doctor will take the attitude "pills for your symptoms, talk for your problems".

Psychological therapy should always accompany medication in major cases of depression.

There are many forms of therapy, from one-off counselling in your doctor's surgery to a course of cognitive-behavioural psychotherapy lasting several months. Although there is strong evidence that depression is mainly a biological problem, originating from defective brain chemistry and amenable to drug treatment, it's also evident that therapy may bring about more long-lasting changes. Some research has shown that therapy can be as good as medication, especially in the long term.

For depression, the best type of therapy is cognitive behavioural therapy (CBT) – at least according to the clinical studies that have been done. CBT involves relearning the negative thinking patterns that lie at the heart of depression.

But CBT is not for everyone. It tends to work better for people with mild depression who can't (or won't) take antidepressants and for those who are willing to take an active part in their treatment. (CBT involves a certain amount of homework, such as keeping a diary of daily activity.) It also works best with people who are psychologically minded, with an interest in exploring how they came to develop depression.

Patients who strongly believe that depression is due solely to a chemical imbalance in their brain are unlikely to benefit from any form of psychological therapy until they change their mind.

How can I help myself?

If you know you suffer from depression, there are a number of self-help measures you could try out.

  • Diet. It could be important to check your diet for sufficient levels of B vitamins, especially folic acid. A deficiency of folic acid has recently been linked to heart disease and Alzheimer's disease, but could also be important in depression. You can get folic acid from fortified breakfast cereals and green vegetables. In fact, a diet rich in fruits and vegetables will protect your brain (via their antioxidant properties) from the kind of malfunctioning chemistry that can lead to depression.
  • Exercise. Some enlightened doctors now prescribe swimming or gym tickets in place of (or alongside) antidepressants, because it's well known that exercise improves self-esteem, perhaps by improving the blood supply to the brain.
  • Herbal remedies. You can buy St John's Wort to improve your mood. It's the only over-the-counter remedy for depression, and there are now many studies underway that show it is effective for treating depression and SAD. There is also 5-hydroxytryptophan (5-HT), the chemical from which serotonin is made in the body – this is now available in health-food shops and can be used as a "natural" treatment for depression. These remedies shouldn't be taken at the same time as any prescribed antidepressants.

What's the outlook?

Depressive illness tends to fluctuate over time with a tendency to recurrent episodes. Once depression has been diagnosed, you will need to prevent further problems by taking medication as prescribed and/or taking part in psychological therapy.




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