Difference between revisions of "Clinical depression" - New World Encyclopedia

From New World Encyclopedia
m (Protected "Clinical depression": Completed ([Edit=Allow only administrators] (indefinite) [Move=Allow only administrators] (indefinite)))
(45 intermediate revisions by the same user not shown)
Line 1: Line 1:
 
+
{{Images OK}}{{Submitted}}{{Approved}}{{Copyedited}}
 
{{Infobox medical condition (new)
 
{{Infobox medical condition (new)
 
| name          = Clinical depression
 
| name          = Clinical depression
Line 25: Line 25:
 
'''Clinical Depression''', also known as '''Major Depressive Disorder''' ('''MDD'''), is a [[mental disorder]] characterized by pervasive [[depression (mood)|low mood]], low [[self-esteem]], and [[anhedonia|loss of interest or pleasure]] in normally enjoyable activities over a protracted period of time.  
 
'''Clinical Depression''', also known as '''Major Depressive Disorder''' ('''MDD'''), is a [[mental disorder]] characterized by pervasive [[depression (mood)|low mood]], low [[self-esteem]], and [[anhedonia|loss of interest or pleasure]] in normally enjoyable activities over a protracted period of time.  
  
The diagnosis of major depressive disorder is based on the person's reported experiences, behavior reported by relatives or friends, and a [[mental status examination]]. The course of the disorder varies widely, from one episode lasting months to a lifelong disorder with recurrent [[major depressive episode]]s.
+
The diagnosis of major depressive disorder is based on the person's reported experiences, behavior reported by relatives or friends, and a [[mental status examination]]. The course of the disorder varies widely, from one episode lasting months to a lifelong disorder with recurrent [[major depressive episode]]s. Major depressive disorder is believed to be caused by a combination of [[genetics|genetic]], environmental, and psychological factors. Risk factors include a [[Family history (medicine)|family history]] of the condition, major life changes, certain medications, [[chronic health problem]]s, and [[substance use disorder]]s. Those suffering from clinical depression are typically treated with [[psychotherapy]] and [[antidepressant medication]]. 
 
 
Major depressive disorder is believed to be caused by a combination of [[genetics|genetic]], environmental, and psychological factors. Risk factors include a [[Family history (medicine)|family history]] of the condition, major life changes, certain medications, [[chronic health problem]]s, and [[substance use disorder]]s.  
 
 
{{toc}}
 
{{toc}}
Those with major depressive disorder are typically treated with [[psychotherapy]] and [[antidepressant medication]].
+
Despite efforts to educate the public about [[mental disorder]]s, social stigma continues to make it difficult both for those suffering from serious depression to admit their problems and for health professionals to diagnose and treat them. The view held by some psychiatrists that such depression is merely a social construct or imagined illness that is inappropriately regarded as an actual disease compounds these difficulties. Compassion as well as support for effective treatment is needed to allow those suffering from depression to receive appropriate and effective treatment so that they may be successful members of society.
  
 
==Terminology==
 
==Terminology==
Line 81: Line 79:
 
[[Rating scale]]s are not used to diagnose depression, but they provide an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose, including the [[Hamilton Rating Scale for Depression]], the [[Beck Depression Inventory]], and the [[Suicide Behaviors Questionnaire-Revised]].
 
[[Rating scale]]s are not used to diagnose depression, but they provide an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose, including the [[Hamilton Rating Scale for Depression]], the [[Beck Depression Inventory]], and the [[Suicide Behaviors Questionnaire-Revised]].
  
Specialist mental health services are rare in rural areas, especially in developing countries, and thus diagnosis and management is left largely to [[primary care|primary-care]] clinicians. Since primary-care physicians have more difficulty with underrecognition and undertreatment of depression compared to psychiatrists, they often miss cases where people experience physical symptoms accompanying their depression.  
+
Specialist mental health services are rare in rural areas, especially in developing countries, and thus diagnosis and management is left largely to [[primary care|primary-care]] clinicians. Since primary-care physicians have more difficulty with under-recognition and under-treatment of depression compared to psychiatrists, they often miss cases where people experience physical symptoms accompanying their depression.  
  
 
A doctor generally performs a medical examination and selected investigations to rule out other causes of depressive symptoms. These can include blood tests to exclude [[hypothyroidism]] and [[Metabolic disorder|metabolic disturbance]], or a [[systemic infection]] or chronic disease.[[Testosterone]] levels may be evaluated to diagnose [[hypogonadism]], a cause of depression in men. Adverse affective reactions to medications or alcohol misuse may be ruled out, as well. Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a [[dementia|dementing disorder]], such as [[Alzheimer's disease]], which can be rule out through [[Neuropsychological assessment|Cognitive testing]] and brain imaging.
 
A doctor generally performs a medical examination and selected investigations to rule out other causes of depressive symptoms. These can include blood tests to exclude [[hypothyroidism]] and [[Metabolic disorder|metabolic disturbance]], or a [[systemic infection]] or chronic disease.[[Testosterone]] levels may be evaluated to diagnose [[hypogonadism]], a cause of depression in men. Adverse affective reactions to medications or alcohol misuse may be ruled out, as well. Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a [[dementia|dementing disorder]], such as [[Alzheimer's disease]], which can be rule out through [[Neuropsychological assessment|Cognitive testing]] and brain imaging.
Line 119: Line 117:
 
The pathophysiology of depression is not completely understood. The most common and effective treatments are [[psychotherapy]], medication, and [[electroconvulsive therapy]] (ECT); a combination of treatments being the most effective approach.  
 
The pathophysiology of depression is not completely understood. The most common and effective treatments are [[psychotherapy]], medication, and [[electroconvulsive therapy]] (ECT); a combination of treatments being the most effective approach.  
  
[[American Psychiatric Association]] treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and personal preference. Options may include pharmacotherapy, psychotherapy, exercise, ECT, [[transcranial magnetic stimulation]] (TMS), or [[light therapy]]. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all people with severe depression unless ECT is planned.<ref>[https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-1410197717630.pdf Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition] ''American Psychiatric Association'', 2010. Retrieved October 17, 2022.</ref>
+
[[American Psychiatric Association]] treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and personal preference. Options may include pharmacotherapy, psychotherapy, exercise, ECT, [[transcranial magnetic stimulation]] (TMS), or [[light therapy]]. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all people with severe depression unless ECT is planned.<ref name=APAGuideline>[https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-1410197717630.pdf Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition] ''American Psychiatric Association'', 2010. Retrieved October 17, 2022.</ref>
 
===Lifestyle===
 
[[Physical exercise]] has been found to be effective for major depression, and may be recommended to people who are willing, motivated, and healthy enough to participate in an exercise program as treatment. Sleep and diet may also play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.<ref>Adrian L. Lopresti, Sean D. Hood, Peter D. Drummond, [https://pubmed.ncbi.nlm.nih.gov/23415826/ A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise] ''Journal of Affective Disorders'' 148(1) (May 2013): 12–27. Retrieved October 17, 2022. </ref>  
 
  
===Talking therapies===
+
===Talk therapies===
[[Talking therapy]] (psychotherapy) can be delivered to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical [[social work]]ers, counselors, and psychiatric nurses. A 2012 review found psychotherapy to be better than no treatment but not other treatments.<ref>{{cite journal | vauthors = Khan A, Faucett J, Lichtenberg P, Kirsch I, Brown WA | title = A systematic review of comparative efficacy of treatments and controls for depression | journal = PLOS ONE | volume = 7 | issue = 7 | pages = e41778 | date = 30 July 2012 | pmid = 22860015 | pmc = 3408478 | doi = 10.1371/journal.pone.0041778 | bibcode = 2012PLoSO...741778K | doi-access = free }}</ref> With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.<ref>{{cite journal | vauthors = Thase ME | title = When are psychotherapy and pharmacotherapy combinations the treatment of choice for major depressive disorder? | journal = The Psychiatric Quarterly | volume = 70 | issue = 4 | pages = 333–46 | year = 1999 | pmid = 10587988 | doi = 10.1023/A:1022042316895 | s2cid = 45091134 }}</ref><ref>{{cite encyclopedia| vauthors = Cordes J |title=Encyclopedia of Sciences and Religions |pages=610–16 |year=2013 |doi=10.1007/978-1-4020-8265-8_301 |chapter=Depression |isbn=978-1-4020-8264-1 }}</ref> There is moderate-quality evidence that psychological therapies are a useful addition to standard antidepressant treatment of [[treatment-resistant depression]] in the short term.<ref>{{cite journal | vauthors = Ijaz S, Davies P, Williams CJ, et al | title = Psychological therapies for treatment-resistant depression in adults | journal = The Cochrane Database of Systematic Reviews | volume = 5 | pages = CD010558 | date = May 2018 | issue = 8 | pmid = 29761488 | pmc = 6494651 | doi = 10.1002/14651858.CD010558.pub2 }}</ref> Psychotherapy has been shown to be effective in older people.<ref>{{cite journal |vauthors=Wilson KC, Mottram PG, Vassilas CA |title=Psychotherapeutic treatments for older depressed people |journal=The Cochrane Database of Systematic Reviews |volume=23 |issue=1 |page=CD004853 |date=January 2008 |pmid=18254062 |doi=10.1002/14651858.CD004853.pub2 }}</ref><ref>{{cite journal |vauthors=Cuijpers P, van Straten A, Smit F |title=Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials |journal=International Journal of Geriatric Psychiatry |volume=21 |issue=12 |pages=1139–49 |date=December 2006 |pmid=16955421 |doi=10.1002/gps.1620 |hdl=1871/16894 |s2cid=14778731 |url=https://research.vu.nl/en/publications/5a654ac9-4dbf-4df9-9d2c-2cbc760d8bc9 }}</ref> Successful psychotherapy appears to reduce the recurrence of depression even after it has been stopped or replaced by occasional booster sessions.
+
Talk therapy, or [[psychotherapy]] can be delivered to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical [[social work]]ers, counselors, and psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.
  
The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. CBT can perform as well as antidepressants in people with major depression.<ref>{{cite journal | vauthors = Gartlehner G, Wagner G, Matyas N, et al | title = Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews | journal = BMJ Open | volume = 7 | issue = 6 | pages = e014912 | date = June 2017 | pmid = 28615268 | pmc = 5623437 | doi = 10.1136/bmjopen-2016-014912 }}</ref> CBT has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy (IPT) are preferred therapies for adolescent depression.<ref name=abct>[https://web.archive.org/web/20110726055131/http://www.abct.org/sccap/?m=sPublic&fa=pub_Depression Childhood Depression]. abct.org. Last updated: 30 July 2010</ref> In people under 18, according to the [[National Institute for Health and Clinical Excellence]], medication should be offered only in conjunction with a psychological therapy, such as [[Cognitive behavioral therapy|CBT]], [[Interpersonal psychotherapy|interpersonal therapy]], or [[family therapy]].<ref name=NICEkids5>{{cite book |title=NICE guidelines: Depression in children and adolescents |publisher=NICE |location=London |year=2005 |page=5 |isbn=978-1-84629-074-9 |url=http://www.nice.org.uk/Guidance/CG28/QuickRefGuide/pdf/English |access-date=16 August 2008 |url-status=live |archive-url=https://web.archive.org/web/20080924152314/http://www.nice.org.uk/Guidance/CG28/QuickRefGuide/pdf/English |archive-date=24 September 2008 |author-link=National Institute for Health and Clinical Excellence }}</ref> Several variables predict success for cognitive behavioral therapy in adolescents: higher levels of rational thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive distortions.<ref>{{cite journal |author=Becker SJ|title=Cognitive-Behavioral Therapy for Adolescent Depression: Processes of Cognitive Change |journal=Psychiatric Times|volume=25 |issue=14 |year=2008 |url=http://www.psychiatrictimes.com/depression/article/10168/1357884}}</ref> CBT is particularly beneficial in preventing relapse.<ref>{{cite journal |vauthors=Almeida AM, Lotufo Neto F |title=[Cognitive-behavioral therapy in prevention of depression relapses and recurrences: a review] |journal=Revista Brasileira de Psiquiatria |volume=25 |issue=4 |pages=239–44 |date=October 2003 |pmid=15328551 |doi=10.1590/S1516-44462003000400011|doi-access=free }}</ref><ref>{{cite journal |vauthors=Paykel ES |title=Cognitive therapy in relapse prevention in depression |journal=The International Journal of Neuropsychopharmacology |volume=10 |issue=1 |pages=131–36 |date=February 2007 |pmid=16787553 |doi=10.1017/S1461145706006912 |doi-access=free }}</ref> Cognitive behavioral therapy and occupational programs (including modification of work activities and assistance) have been shown to be effective in reducing sick days taken by workers with depression.<ref name=Nieuwenhuijsen2020/> Several variants of cognitive behavior therapy have been used in those with depression, the most notable being [[rational emotive behavior therapy]],{{sfn|Beck|Rush|Shaw|Emery|1987|p=10}} and [[mindfulness-based cognitive therapy]].<ref>{{cite journal |vauthors=Coelho HF, Canter PH, Ernst E |title=Mindfulness-based cognitive therapy: evaluating current evidence and informing future research |journal=Journal of Consulting and Clinical Psychology |volume=75 |issue=6 |pages=1000–05 |date=December 2007 |pmid=18085916 |doi=10.1037/0022-006X.75.6.1000 }}</ref> Mindfulness-based stress reduction programs may reduce depression symptoms.<ref>{{cite journal |vauthors=Khoury B, Lecomte T, Fortin G, et al |title=Mindfulness-based therapy: a comprehensive meta-analysis |journal=Clinical Psychology Review |volume=33 |issue=6 |pages=763–71 |date=August 2013 |pmid=23796855 |doi=10.1016/j.cpr.2013.05.005 }}</ref><ref>{{cite journal |vauthors=Jain FA, Walsh RN, Eisendrath SJ, Christensen S, Rael Cahn B |title=Critical analysis of the efficacy of meditation therapies for acute and subacute phase treatment of depressive disorders: a systematic review |journal=Psychosomatics |volume=56 |issue=2 |pages=140–52 |year=2014 |pmid=25591492 |pmc=4383597 |doi=10.1016/j.psym.2014.10.007 |url=http://www.escholarship.org/uc/item/0372c9xp }}</ref> Mindfulness programs also appear to be a promising intervention in youth.<ref>{{cite journal |vauthors=Simkin DR, Black NB |title=Meditation and mindfulness in clinical practice |journal=Child and Adolescent Psychiatric Clinics of North America |volume=23 |issue=3 |pages=487–534 |date=July 2014 |pmid=24975623 |doi=10.1016/j.chc.2014.03.002 }}</ref> [[Problem solving therapy]], cognitive behavioral therapy, and interpersonal therapy are effective interventions in the elderly.<ref name="Alexopoulos2019" />
+
The most commonly used form of psychotherapy for depression is [[Cognitive Behavioral Therapy]] (CBT), which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. CBT and interpersonal psychotherapy (IPT) are preferred treatments for adolescent depression; in people under 18, according to the [[National Institute for Health and Clinical Excellence]], medication should be offered only in conjunction with a psychological therapy, such as CBT, [[Interpersonal psychotherapy|interpersonal therapy]], or [[family therapy]].<ref>National Institute for Health and Clinical Excellence (NICE), [https://www.nice.org.uk/guidance/ng134/chapter/Recommendations How to use antidepressants in children and young people] ''Depression in children and young people: identification and management NICE guideline'', June 25, 2019. Retrieved October 17, 2022. </ref> Several variants of cognitive behavior therapy have been used in treating depression, the most notable being [[rational emotive behavior therapy]]<ref name=Beck/> and [[mindfulness-based cognitive therapy]].<ref>Helen F. Coelho, Peter H. Canter, and Edzard Ernst, [https://pubmed.ncbi.nlm.nih.gov/18085916/ Mindfulness-based cognitive therapy: evaluating current evidence and informing future research] ''Journal of Consulting and Clinical Psychology'' 75(6) (December 2007): 1000–1005. Retrieved October 17, 2022.</ref>
  
[[Psychoanalysis]] is a school of thought, founded by [[Sigmund Freud]], which emphasizes the resolution of [[Unconscious mind|unconscious]] mental conflicts.<ref>{{cite book |vauthors=Dworetzky J |title=Psychology |publisher=Brooks/Cole Pub. Co |location=Pacific Grove, CA|year=1997 |page=602 |isbn=978-0-314-20412-7}}</ref> Psychoanalytic techniques are used by some practitioners to treat clients presenting with major depression.<ref>{{cite journal |vauthors=Doidge N, Simon B, Lancee WJ, et al |title=Psychoanalytic patients in the U.S., Canada, and Australia: II. A DSM-III-R validation study |journal=Journal of the American Psychoanalytic Association |volume=50 |issue=2 |pages=615–27 |year=2002 |pmid=12206545 |doi=10.1177/00030651020500021101 |s2cid=25110425 }}</ref> A more widely practiced therapy, called [[psychodynamic psychotherapy]], is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus.{{sfn|Barlow|Durand|2005|p=20}} In a meta-analysis of three controlled trials of Short Psychodynamic Supportive Psychotherapy, this modification was found to be as effective as medication for mild to moderate depression.<ref>{{cite journal |vauthors=de Maat S, Dekker J, Schoevers R, et al |title=Short psychodynamic supportive psychotherapy, antidepressants, and their combination in the treatment of major depression: a mega-analysis based on three randomized clinical trials |journal=Depression and Anxiety |volume=25 |issue=7 |pages=565–74 |year=2007 |pmid=17557313 |doi=10.1002/da.20305 |s2cid=20373635 }}</ref>
+
[[Psychoanalysis]], founded by [[Sigmund Freud]], emphasizes the resolution of [[unconscious]] mental conflicts, and has been used to treat patients with major depression. A more widely practiced therapy, called [[psychodynamic psychotherapy]], is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus.<ref name=Barlow>David H. Barlow, Vincent Mark Durand, and Stefan G. Hofmann, ''Abnormal Psychology: An Integrative Approach (8th edition)'' (Cengage Learning, 2017, ISBN 978-1305950443).</ref>
  
 
===Antidepressants===
 
===Antidepressants===
Conflicting results have arisen from studies that look at the effectiveness of antidepressants in people with acute, mild to moderate depression.<ref>{{cite journal | vauthors = Iglesias-González M, Aznar-Lou I, Gil-Girbau M, et al | title = Comparing watchful waiting with antidepressants for the management of subclinical depression symptoms to mild-moderate depression in primary care: a systematic review | journal = Family Practice | volume = 34 | issue = 6 | pages = 639–48 | date = November 2017 | pmid = 28985309 | doi = 10.1093/fampra/cmx054 | doi-access = free }}</ref> A review commissioned by the [[National Institute for Health and Care Excellence]] (UK) concluded that there is strong evidence that [[selective serotonin reuptake inhibitor|SSRIs]], such as [[escitalopram]], [[paroxetine]], and [[sertraline]], have greater efficacy than [[placebo]] on achieving a 50% reduction in depression scores in moderate and severe major depression, and that there is some evidence for a similar effect in mild depression.<ref name="Depression in Adults">{{cite web|title=The treatment and management of depression in adults|url=http://www.nice.org.uk/guidance/cg90/resources/guidance-depression-in-adults-pdf|publisher=[[NICE]]|date=October 2009|access-date=12 November 2014|url-status=live|archive-url=https://web.archive.org/web/20141112140520/http://www.nice.org.uk/guidance/cg90/resources/guidance-depression-in-adults-pdf|archive-date=12 November 2014}}</ref> Similarly, a Cochrane systematic review of clinical trials of the generic [[tricyclic antidepressant]] [[amitriptyline]] concluded that there is strong evidence that its efficacy is superior to placebo.<ref>{{cite journal |vauthors=Leucht C, Huhn M, Leucht S |title=Amitriptyline versus placebo for major depressive disorder |journal=The Cochrane Database of Systematic Reviews |volume=12 |pages=CD009138 |date=December 2012 |pmid=23235671 |doi=10.1002/14651858.CD009138.pub2 |editor1-last=Leucht |editor1-first=C }}</ref> Antidepressants work less well for the elderly than for younger individuals with depression.<ref name="Alexopoulos2019">{{cite journal |vauthors=Alexopoulos GS |date=August 2019 |title=Mechanisms and treatment of late-life depression |journal=Transl Psychiatry |volume=9 |issue=1 |pages=188 |doi=10.1038/s41398-019-0514-6 |pmc=6683149 |pmid=31383842}}</ref>
+
Antidepressants are commonly prescribed to treat major depressive disorder. The treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is often recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.<ref name=NIMHPub/>
 
 
To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. Response rates to the first antidepressant administered range from 50 to 75%, and it can take at least six to eight weeks from the start of medication to improvement.<ref name=apaguidelines /><ref>{{cite journal | vauthors = de Vries YA, Roest AM, Bos EH, et al | title = Predicting antidepressant response by monitoring early improvement of individual symptoms of depression: individual patient data meta-analysis | journal = The British Journal of Psychiatry | volume = 214 | issue = 1 | pages = 4–10 | date = January 2019 | pmid = 29952277 | doi = 10.1192/bjp.2018.122 | pmc = 7557872 | doi-access = free }}</ref> Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence,<!--This study is from 2000- is there not something more recent?—><ref name=apaguidelines>{{cite journal | title = Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association | journal = The American Journal of Psychiatry | volume = 157 | issue = 4 Suppl | pages = 1–45 | date = April 2000 | pmid = 10767867 }}; Third edition {{doi|10.1176/appi.books.9780890423363.48690}}</ref> and even up to one year of continuation is recommended.<ref>{{cite journal | vauthors = Thase ME | title = Preventing relapse and recurrence of depression: a brief review of therapeutic options | journal = CNS Spectrums | volume = 11 | issue = 12 Suppl 15 | pages = 12–21 | date = December 2006 | pmid = 17146414 | doi = 10.1017/S1092852900015212 | s2cid = 2347144 }}</ref> People with chronic depression may need to take medication indefinitely to avoid relapse.<ref name=NIMHPub/>
 
 
 
[[Selective serotonin reuptake inhibitor|SSRIs]] are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants.<ref name=2008-BNF-204>{{Harvnb|Royal Pharmaceutical Society of Great Britain|2008|p=204}}</ref> People who do not respond to one SSRI can be switched to [[List of antidepressants|another antidepressant]], and this results in improvement in almost 50% of cases.<!--per the WP:MEDRS guideline, review articles should ideally be less than 5 yrs, pref. less than 3 years old—><ref>{{cite journal | vauthors = Whooley MA, Simon GE | title = Managing depression in medical outpatients | journal = The New England Journal of Medicine | volume = 343 | issue = 26 | pages = 1942–50 | date = December 2000 | pmid = 11136266 | doi = 10.1056/NEJM200012283432607 }}</ref> Another option is to switch to the atypical antidepressant [[bupropion]].<ref>{{cite journal | vauthors = Zisook S, Rush AJ, Haight BR, Clines DC, Rockett CB | title = Use of bupropion in combination with serotonin reuptake inhibitors | journal = Biological Psychiatry | volume = 59 | issue = 3 | pages = 203–10 | date = February 2006 | pmid = 16165100 | doi = 10.1016/j.biopsych.2005.06.027 | s2cid = 20997303 }}</ref> [[Venlafaxine]], an antidepressant with a different mechanism of action, may be modestly more effective than SSRIs.<ref>{{cite journal | vauthors = Papakostas GI, Thase ME, Fava M, Nelson JC, Shelton RC | title = Are antidepressant drugs that combine serotonergic and noradrenergic mechanisms of action more effective than the selective serotonin reuptake inhibitors in treating major depressive disorder? A meta-analysis of studies of newer agents | journal = Biological Psychiatry | volume = 62 | issue = 11 | pages = 1217–27 | date = December 2007 | pmid = 17588546 | doi = 10.1016/j.biopsych.2007.03.027 | s2cid = 45621773 }}</ref> However, venlafaxine is not recommended in the UK as a first-line treatment because of evidence suggesting its risks may outweigh benefits,<ref>{{cite web |url=http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dDocName=CON2023842&RevisionSelectionMethod=LatestReleased |title=Updated prescribing advice for venlafaxine (Efexor/Efexor XL) |author=Gordon Duff |publisher=Medicines and Healthcare products Regulatory Agency (MHRA) |date=31 May 2006 |url-status=dead |archive-url=https://web.archive.org/web/20081113133358/http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dDocName=CON2023842&RevisionSelectionMethod=LatestReleased |archive-date=13 November 2008 |author-link=Gordon Duff }}</ref> and it is specifically discouraged in children and adolescents.<ref>{{cite journal|title=Depression in children and young people: Identification and management in primary, community and secondary care|year=2005|publisher=NHS National Institute for Health and Clinical Excellence|journal=NICE Clinical Guidelines|issue=28|access-date=12 November 2014|url=http://www.nice.org.uk/guidance/cg28/resources/guidance-depression-in-children-and-young-people-pdf|url-status=dead|archive-url=https://web.archive.org/web/20141112133741/http://www.nice.org.uk/guidance/cg28/resources/guidance-depression-in-children-and-young-people-pdf|archive-date=12 November 2014}}</ref><ref>{{cite journal | vauthors = Mayers AG, Baldwin DS | title = Antidepressants and their effect on sleep | journal = Human Psychopharmacology | volume = 20 | issue = 8 | pages = 533–59 | date = December 2005 | pmid = 16229049 | doi = 10.1002/hup.726 | s2cid = 17912673 }}</ref>
 
 
 
<!-- Children —>
 
For children, some research has supported the use of the SSRI antidepressant [[fluoxetine]].<ref name=Lancet2016Kid>{{cite journal |vauthors=Cipriani A, Zhou X, Del Giovane C, et al |title=Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis |journal=Lancet |volume=388 |issue=10047 |pages=881–90 |date=August 2016 |pmid=27289172 |doi=10.1016/S0140-6736(16)30385-3 |hdl=11380/1279478 |s2cid=19728203 |url=https://ora.ox.ac.uk/objects/uuid:e0b5ae23-d562-4348-94b8-84f70b7812c5 }}</ref> The benefit however appears to be slight in children,<ref name=Lancet2016Kid/><ref>{{cite journal |vauthors=Tsapakis EM, Soldani F, Tondo L, Baldessarini RJ |title=Efficacy of antidepressants in juvenile depression: meta-analysis |journal=The British Journal of Psychiatry |volume=193 |issue=1 |pages=10–17 |date=July 2008 |pmid=18700212 |doi=10.1192/bjp.bp.106.031088 |doi-access=free }}</ref> while other antidepressants have not been shown to be effective.<ref name=Lancet2016Kid/> Medications are not recommended in children with mild disease.<ref>{{cite journal | vauthors = Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein RE | title = Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management | journal = Pediatrics | volume = 141 | issue = 3 | page = e20174082 | date = February 2018 | pmid = 29483201 | doi = 10.1542/peds.2017-4082 | doi-access = free }}</ref> There is also insufficient evidence to determine effectiveness in those with depression complicated by [[dementia]].<ref>{{cite journal |vauthors=Nelson JC, Devanand DP |title=A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia |journal=Journal of the American Geriatrics Society |volume=59 |issue=4 |pages=577–85 |date=April 2011 |pmid=21453380 |doi=10.1111/j.1532-5415.2011.03355.x |s2cid=2592434 }}</ref> Any antidepressant can cause [[hyponatremia|low blood sodium]] levels;<ref>{{cite journal |vauthors=Palmer BF, Gates JR, Lader M |title=Causes and management of hyponatremia |journal=The Annals of Pharmacotherapy |volume=37 |issue=11 |pages=1694–702 |date=November 2003 |pmid=14565794 |doi=10.1345/aph.1D105 |s2cid=37965495 }}</ref> nevertheless, it has been reported more often with SSRIs.<ref name=2008-BNF-204 /> It is not uncommon for SSRIs to cause or worsen insomnia; the sedating [[atypical antidepressant]] [[mirtazapine]] can be used in such cases.<ref>{{cite journal |vauthors=Guaiana G, Barbui C, Hotopf M |title=Amitriptyline for depression |journal=The Cochrane Database of Systematic Reviews |volume=18 |issue=3 |page=CD004186 |date=July 2007 |pmid=17636748 |doi=10.1002/14651858.CD004186.pub2 }}</ref><ref>{{cite journal |vauthors=Anderson IM |title=Selective serotonin reuptake inhibitors versus tricyclic antidepressants: a meta-analysis of efficacy and tolerability |journal=Journal of Affective Disorders |volume=58 |issue=1 |pages=19–36 |date=April 2000 |pmid=10760555 |doi=10.1016/S0165-0327(99)00092-0 }}</ref>
 
  
Irreversible [[monoamine oxidase inhibitor]]s, an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better-tolerated agents of this class have been developed.<ref>{{cite journal |vauthors=Krishnan KR |title=Revisiting monoamine oxidase inhibitors |journal=The Journal of Clinical Psychiatry |volume=68 |issue=Suppl 8 |pages=35–41 |year=2007 |pmid=17640156 }}</ref> The safety profile is different with reversible monoamine oxidase inhibitors, such as [[moclobemide]], where the risk of serious dietary interactions is negligible and dietary restrictions are less strict.<ref>{{cite journal |vauthors=Bonnet U |title=Moclobemide: therapeutic use and clinical studies |journal=CNS Drug Reviews |volume=9 |issue=1 |pages=97–140 |year=2003 |pmid=12595913 |pmc=6741704 |doi=10.1111/j.1527-3458.2003.tb00245.x }}</ref>
+
The UK [[National Institute for Health and Care Excellence]] (NICE) guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk to benefit ratio is poor. The guidelines recommended that antidepressant treatment be considered for:
  
<!--SSRI and suicide —>
+
* People with a history of moderate or severe depression
It is unclear whether antidepressants affect a person's risk of suicide.<ref>{{cite journal |vauthors=Braun C, Bschor T, Franklin J, Baethge C |title=Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder |journal=Psychotherapy and Psychosomatics |volume=85 |issue=3 |pages=171–79 |year=2016 |pmid=27043848 |doi=10.1159/000442293 |s2cid=40682753 |url=https://tud.qucosa.de/id/qucosa%3A70596 }}</ref> For children, adolescents, and probably young adults between 18 and 24 years old, there is a higher risk of both [[suicidal ideation]]s and [[suicidal behavior]] in those treated with SSRIs.<ref name=FDA>{{cite web |url=https://www.fda.gov/OHRMS/DOCKETS/ac/04/briefing/2004-4065b1-10-TAB08-Hammads-Review.pdf|title=Review and evaluation of clinical data. Relationship between psychiatric drugs and pediatric suicidality|access-date=29 May 2008|vauthors=Hammad TA|date=16 August 2004|publisher=FDA|pages=42, 115|url-status=live|archive-url=https://web.archive.org/web/20080625161255/https://www.fda.gov/OHRMS/DOCKETS/ac/04/briefing/2004-4065b1-10-TAB08-Hammads-Review.pdf|archive-date=25 June 2008}}</ref><ref>{{cite journal |vauthors=Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN |title=Newer generation antidepressants for depressive disorders in children and adolescents |journal=The Cochrane Database of Systematic Reviews |volume=11 |page=CD004851 |date=November 2012 |issue=9 |pmid=23152227 |doi=10.1002/14651858.CD004851.pub3 |pmc=8786271 |hdl=11343/59246 |hdl-access=free }}</ref> For adults, it is unclear whether SSRIs affect the risk of suicidality. One review found no connection;<ref>{{cite journal |vauthors=Gunnell D, Saperia J, Ashby D |title=Selective serotonin reuptake inhibitors (SSRIs) and suicide in adults: meta-analysis of drug company data from placebo controlled, randomised controlled trials submitted to the MHRA's safety review |journal=BMJ |volume=330 |issue=7488 |page=385 |date=February 2005 |pmid=15718537 |pmc=549105 |doi=10.1136/bmj.330.7488.385 }}</ref> another an increased risk;<ref>{{cite journal |vauthors=Fergusson D, Doucette S, Glass KC, et al|title=Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials |journal=BMJ |volume=330 |issue=7488 |pages=396 |date=February 2005 |pmid=15718539 |pmc=549110 |doi=10.1136/bmj.330.7488.396 }}</ref> and a third no risk in those 25–65 years old and a decreased risk in those more than 65.<ref>{{cite journal |vauthors=Stone M, Laughren T, Jones ML, et al |title=Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration |journal=BMJ |volume=339 |page=b2880 |date=August 2009 |pmid=19671933 |pmc=2725270 |doi=10.1136/bmj.b2880 }}</ref> A [[black box warning]] was introduced in the United States in 2007 on SSRIs and other antidepressant medications due to the increased risk of suicide in people younger than 24 years old.<ref>{{cite web |url=https://www.fda.gov/bbs/topics/NEWS/2007/NEW01624.html |title=FDA Proposes New Warnings About Suicidal Thinking, Behavior in Young Adults Who Take Antidepressant Medications |date=2 May 2007 |publisher=[[U.S. Food and Drug Administration|FDA]] |access-date=29 May 2008 |url-status=live |archive-url=https://web.archive.org/web/20080223195544/https://www.fda.gov/bbs/topics/NEWS/2007/NEW01624.html |archive-date=23 February 2008 }}</ref> Similar precautionary notice revisions were implemented by the Japanese Ministry of Health.<ref>{{cite report |author=Medics and Foods Department |author-link=Ministry of Health, Labour and Welfare (Japan) |url=http://www1.mhlw.go.jp/kinkyu/iyaku_j/iyaku_j/anzenseijyouhou/261.pdf |title=Pharmaceuticals and Medical Devices Safety Information |series=261 |publisher=Ministry of Health, Labour and Welfare (Japan) |language=ja |url-status=dead |archive-url=https://web.archive.org/web/20110429200312/http://www1.mhlw.go.jp/kinkyu/iyaku_j/iyaku_j/anzenseijyouhou/261.pdf |archive-date=29 April 2011 |access-date=19 May 2010 }}</ref>
+
* Those with mild depression that has been present for a long period
 +
* As a second-line treatment for mild depression that persists after other interventions
 +
* As a first-line treatment for moderate or severe depression
  
===Other medications and supplements===
+
The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least six months to reduce the risk of relapse, and that [[selective serotonin reuptake inhibitor]] (SSRIs) are typically better tolerated than other antidepressants.<ref>National Collaborating Centre for Mental Health (NCCMH), ''Depression: The NICE Guideline on the Treatment and Management of Depression in Adults'' (RCPsych Publications, 2010, ISBN 978-1904671855). </ref> To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried.
The combined use of antidepressants plus [[benzodiazepine]]s demonstrates improved effectiveness when compared to antidepressants alone, but these effects may not endure. The addition of a benzodiazepine is balanced against possible harms and other alternative treatment strategies when antidepressant mono-therapy is considered inadequate.<ref name=Ogawa2019>{{cite journal | vauthors = Ogawa Y, Takeshima N, Hayasaka Y, et al| title = Antidepressants plus benzodiazepines for adults with major depression | journal = The Cochrane Database of Systematic Reviews | volume = 6 | pages = CD001026 | date = June 2019 | pmid = 31158298 | pmc = 6546439 | doi = 10.1002/14651858.CD001026.pub2 }}</ref><!-- cites paragraph —>
 
  
[[Ketamine]] may have a rapid antidepressant effect lasting less than two weeks; there is limited evidence of any effect after that, common acute side effects, and longer-term studies of safety and adverse effects are needed.<ref>{{cite journal |vauthors=Corriger A, Pickering G |title=Ketamine and depression: a narrative review |journal=Drug Des Devel Ther |volume=13 |issue= |pages=3051–3067 |date=2019 |pmid=31695324 |pmc=6717708 |doi=10.2147/DDDT.S221437 }}</ref><ref>{{cite journal |vauthors=Krystal JH, Abdallah CG, Sanacora G, Charney DS, Duman RS |title=Ketamine: A Paradigm Shift for Depression Research and Treatment |journal=Neuron |volume=101 |issue=5 |pages=774–778 |date=March 2019 |pmid=30844397 |pmc=6560624 |doi=10.1016/j.neuron.2019.02.005 }}</ref> A nasal spray form of [[esketamine]] was approved by the FDA in March 2019 for use in treatment-resistant depression when combined with an oral antidepressant; risk of substance use disorder and concerns about its safety, serious adverse effects, tolerability, effect on suicidality, lack of information about dosage, whether the studies on it adequately represent broad populations, and escalating use of the product have been raised by an international panel of experts.<ref>{{cite journal |vauthors=McIntyre RS, Rosenblat JD, Nemeroff CB, et al |title=Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation |journal=Am J Psychiatry |volume=178 |issue=5 |pages=383–399 |date=May 2021 |pmid=33726522 |doi=10.1176/appi.ajp.2020.20081251 |s2cid=232262694 |url=https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20081251?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed}}</ref><ref>{{cite journal |vauthors=Bahr R, Lopez A, Rey JA |title=Intranasal Esketamine (SpravatoTM) for Use in Treatment-Resistant Depression In Conjunction With an Oral Antidepressant |journal=P T |volume=44 |issue=6 |pages=340–375 |date=June 2019 |pmid=31160868 |pmc=6534172 }}</ref>
+
[[American Psychiatric Association]] treatment guidelines recommended antidepressant medication as an initial treatment choice in people with mild, moderate, or severe major depression, that should be given to all people with severe depression unless ECT is planned.<ref name=APAGuideline/>
 
 
There is insufficient high quality evidence to suggest [[omega-3 fatty acid]]s are effective in depression.<ref>{{cite journal |vauthors=Appleton KM, Voyias PD, Sallis HM, et al |title=Omega-3 fatty acids for depression in adults |journal=Cochrane Database Syst Rev |volume=2021 |issue= 11|pages=CD004692 |date=November 2021 |pmid=34817851 |doi=10.1002/14651858.CD004692.pub5 |pmc=8612309 |pmc-embargo-date=24 November 2022 }}</ref> There is limited evidence that vitamin D supplementation is of value in alleviating the symptoms of depression in individuals who are vitamin D-deficient.<ref name=Parker2017>{{cite journal |vauthors=Parker GB, Brotchie H, Graham RK |title=Vitamin D and depression |journal=Journal of Affective Disorders |volume=208 |pages=56–61 |date=January 2017 |pmid=27750060 |doi=10.1016/j.jad.2016.08.082 }}</ref> [[Lithium (medication)|Lithium]] appears effective at lowering the risk of suicide in those with bipolar disorder and unipolar depression to nearly the same levels as the general population.<ref>{{cite journal |vauthors=Cipriani A, Hawton K, Stockton S, Geddes JR |title=Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis |journal=BMJ |volume=346 |issue=jun27 4 |page=f3646 |date=June 2013 |pmid=23814104 |doi=10.1136/bmj.f3646 |doi-access=free }}</ref> There is a narrow range of effective and safe dosages of lithium thus close monitoring may be needed.<ref>Nolen-Hoeksema, Susan. (2014) "Treatment of Mood Disorders". In (6th ed.) ''Abnormal Psychology'' p. 196. New York: McGraw-Hill. {{ISBN|978-0-07-803538-8}}.</ref> Low-dose [[thyroid hormone]] may be added to existing antidepressants to treat persistent depression symptoms in people who have tried multiple courses of medication.<ref name="APA MDD Guideline">{{cite web|vauthors=Gelenberg AJ, Freeman MP, Markowitz JC |title=Practice Guideline for the Treatment of Patients with Major Depressive Disorder | edition = 3rd | url = http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf|publisher=American Psychiatric Association (APA)|access-date=3 November 2014}}</ref> Limited evidence suggests [[stimulants]], such as [[amphetamine]] and [[modafinil]], may be effective in the short term, or as [[adjuvant therapy]].<ref>{{cite journal |vauthors=Corp SA, Gitlin MJ, Altshuler LL |title=A review of the use of stimulants and stimulant alternatives in treating bipolar depression and major depressive disorder |journal=The Journal of Clinical Psychiatry |volume=75 |issue=9 |pages=1010–18 |date=September 2014 |pmid=25295426 |doi=10.4088/JCP.13r08851 }}</ref><ref>{{cite journal |vauthors=Malhi GS, Byrow Y, Bassett D, et al |title=Stimulants for depression: On the up and up? |journal=The Australian and New Zealand Journal of Psychiatry |volume=50 |issue=3 |pages=203–07 |date=March 2016 |pmid=26906078 |doi=10.1177/0004867416634208 |s2cid=45341424 }}</ref> Also, it is suggested that [[folate]] supplements may have a role in depression management.<ref>{{cite journal | vauthors = Taylor MJ, Carney S, Geddes J, Goodwin G | title = Folate for depressive disorders | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD003390 |year = 2003 | pmid = 12804463 | doi = 10.1002/14651858.CD003390 | pmc = 6991158 }}</ref> There is tentative evidence for benefit from [[testosterone]] in males.<ref>{{cite journal | vauthors = Walther A, Breidenstein J, Miller R | title = Association of Testosterone Treatment With Alleviation of Depressive Symptoms in Men: A Systematic Review and Meta-analysis | journal = JAMA Psychiatry | volume = 76 | issue = 1 | pages = 31–40 | date = January 2019 | pmid = 30427999 | pmc = 6583468 | doi = 10.1001/jamapsychiatry.2018.2734 }}</ref>
 
  
 
===Electroconvulsive therapy===
 
===Electroconvulsive therapy===
[[Electroconvulsive therapy]] (ECT) is a standard [[psychiatry|psychiatric]] treatment in which [[seizure]]s are electrically induced in a person with depression to provide relief from psychiatric illnesses.<ref>Rudorfer, MV, Henry, ME, Sackeim, HA (2003). [http://media.wiley.com/assets/138/93/UK_Tasman_Chap92.pdf "Electroconvulsive therapy"]. In A Tasman, J Kay, JA Lieberman (eds) ''Psychiatry, Second Edition''. Chichester: John Wiley & Sons Ltd, 1865–1901.</ref>{{rp|1880}} ECT is used with [[informed consent]]<ref name=Beloucif>{{cite journal |vauthors=Beloucif S |title=Informed consent for special procedures: electroconvulsive therapy and psychosurgery |journal=Current Opinion in Anesthesiology |volume=26 |issue=2 |pages=182–85 |date=April 2013 |pmid=23385317 |doi=10.1097/ACO.0b013e32835e7380 |s2cid=36643014 }}</ref> as a last line of intervention for major depressive disorder.<ref name=FDA2011rev>FDA. [https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf FDA Executive Summary] {{webarchive|url=https://web.archive.org/web/20150924161659/https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf |date=24 September 2015 }}. Prepared for the 27–28 January 2011 meeting of the Neurological Devices Panel Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). Quote, p38: "Three major practice guidelines have been published on ECT. These guidelines include: APA Task Force on ECT (2001); Third report of the Royal College of Psychiatrists' Special Committee on ECT (2004); National Institute for Health and Clinical Excellence (NICE 2003; NICE 2009). There is significant agreement between the three sets of recommendations."</ref> A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or [[Bipolar II disorder|bipolar]].<ref>{{cite journal |vauthors=Dierckx B, Heijnen WT, van den Broek WW, Birkenhäger TK |title=Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: a meta-analysis |journal=Bipolar Disorders |volume=14 |issue=2 |pages=146–50 |date=March 2012 |pmid=22420590 |doi=10.1111/j.1399-5618.2012.00997.x |s2cid=44280002 }}</ref> Follow-up treatment is still poorly studied, but about half of people who respond relapse within twelve months.<ref>{{cite journal |vauthors=Jelovac A, Kolshus E, McLoughlin DM |title=Relapse following successful electroconvulsive therapy for major depression: a meta-analysis |journal=Neuropsychopharmacology |volume=38 |issue=12 |pages=2467–74 |date=November 2013 |pmid=23774532 |pmc=3799066 |doi=10.1038/npp.2013.149 }}</ref> Aside from effects in the brain, the general physical risks of ECT are similar to those of brief [[general anesthesia]].<ref name="SG">Surgeon General (1999). [http://www.surgeongeneral.gov/library/mentalhealth/home.html ''Mental Health: A Report of the Surgeon General''] {{webarchive|url=https://web.archive.org/web/20070112012907/http://www.surgeongeneral.gov/library/mentalhealth/home.html |date=12 January 2007 }}, chapter 4.</ref>{{rp|259}} Immediately following treatment, the most common adverse effects are confusion and memory loss.<ref name=FDA2011rev /><ref>{{cite book|agency=American Psychiatric Association|title=The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging|edition=2nd|location=Washington, DC|publisher=American Psychiatric Publishing|year=2001|url=https://books.google.com/books?id=iuuLJtmo_EYC|isbn=978-0-89042-206-9|author=Committee on Electroconvulsive Therapy }}</ref> ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.<ref name=Pompili2014Rev>{{cite journal |vauthors=Pompili M, Dominici G, Giordano G, et al |title=Electroconvulsive treatment during pregnancy: a systematic review |journal=Expert Review of Neurotherapeutics |volume=14 |issue=12 |pages=1377–90 |date=December 2014 |pmid=25346216 |doi=10.1586/14737175.2014.972373 |s2cid=31209001 }}</ref>
+
[[Electroconvulsive therapy]] (ECT), along with antidepressants and psychotherapy, is one of the three major treatments of depression. It has been found to reduce depression symptoms regardless of whether antidepressants are involved. ECT is a standard [[psychiatry|psychiatric]] treatment in which [[seizure]]s are electrically induced in a person with depression to provide relief from psychiatric illnesses. ECT is used with [[informed consent]] as a last line of intervention for major depressive disorder.<ref>Ming Li, Xiaoxiao Yao, et al, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044268/ Effects of Electroconvulsive Therapy on Depression and Its Potential Mechanism] ''Frontiers in Psychology'', 11(80) (2020). Retrieved October 17, 2022.</ref>
  
A usual course of ECT involves multiple administrations, typically given two or three times per week, until the person no longer has symptoms. ECT is administered under [[anesthesia]] with a [[muscle relaxant]].<ref>{{cite web|url=http://psychcentral.com/lib/5-outdated-beliefs-about-ect/00011255|title=5 Outdated Beliefs About ECT|website=Psych Central.com|url-status=live|archive-url=https://web.archive.org/web/20130808042410/http://psychcentral.com/lib/5-outdated-beliefs-about-ect/00011255|archive-date=8 August 2013|date=17 May 2016}}</ref> Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. After treatment, drug therapy is usually continued, and some people receive maintenance ECT.<ref name=FDA2011rev />
+
===Lifestyle===
 
+
[[Physical exercise]] has been found to be effective for major depression, and may be recommended to people who are willing, motivated, and healthy enough to participate in an exercise program as treatment. Sleep and diet may also play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.<ref>Adrian L. Lopresti, Sean D. Hood, Peter D. Drummond, [https://pubmed.ncbi.nlm.nih.gov/23415826/ A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise] ''Journal of Affective Disorders'' 148(1) (May 2013): 12–27. Retrieved October 17, 2022. </ref>
ECT appears to work in the short term via an [[anticonvulsant]] effect mostly in the [[frontal lobes]], and longer term via [[neurotrophic]] effects primarily in the [[medial temporal lobe]].<ref name=Abbott2014>{{cite journal |vauthors=Abbott CC, Gallegos P, Rediske N, Lemke NT, Quinn DK |title=A review of longitudinal electroconvulsive therapy: neuroimaging investigations |journal=Journal of Geriatric Psychiatry and Neurology |volume=27 |issue=1 |pages=33–46 |date=March 2014 |pmid=24381234 |pmc=6624835 |doi=10.1177/0891988713516542 }}</ref>
 
 
 
===Other===
 
[[Transcranial magnetic stimulation]] (TMS) or [[deep transcranial magnetic stimulation]] is a noninvasive method used to stimulate small regions of the brain.<ref>{{Cite web|url=http://www.nice.org.uk/guidance/ipg477/resources/guidance-transcranial-magnetic-stimulation-for-treating-and-preventing-migraine-pdf |title=NiCE. January 2014 Transcranial magnetic stimulation for treating and preventing migraine |url-status=dead |archive-url=https://web.archive.org/web/20151004194631/http://www.nice.org.uk/guidance/ipg477/resources/guidance-transcranial-magnetic-stimulation-for-treating-and-preventing-migraine-pdf |archive-date=4 October 2015 }}</ref> TMS was approved by the FDA for treatment-resistant major depressive disorder (trMDD) in 2008<ref>{{Cite web |url=http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083538.pdf|vauthors=Melkerson MN |date=16 December 2008|title=Special Premarket 510(k) Notification for NeuroStar® TMS Therapy System for Major Depressive Disorder |publisher=Food and Drug Administration. |access-date=16 July 2010 |url-status=live|archive-url=https://web.archive.org/web/20100331000421/http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083538.pdf|archive-date=31 March 2010}}</ref> and as of 2014 evidence supports that it is probably effective.<ref>{{cite journal |vauthors=Lefaucheur JP, André-Obadia N, Antal A, et al|title=Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) |journal=Clinical Neurophysiology |volume=125 |issue=11 |pages=2150–206 |date=November 2014 |pmid=25034472 |doi=10.1016/j.clinph.2014.05.021 |s2cid=206798663 |url=https://hal.archives-ouvertes.fr/hal-03183867/file/S1388245719312799.pdf }}</ref> The American Psychiatric Association,<ref>{{Cite web |url=http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf |publisher=American Psychiatric Association |year=2010 |veditors=Gelenberg AJ, Freeman MP, Markowitz JC, Rosenbaum JF, Thase ME, Trivedi MH, Van Rhoads RS |title=Practice Guidelines for the Treatment of Patients with Major Depressive Disorder |edition=3rd }}</ref> the Canadian Network for Mood and Anxiety Disorders,<ref>{{cite journal | vauthors=Kennedy SH, Lam RW, Parikh SV, Patten SB, Ravindran AV | title=Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults | journal=Journal of Affective Disorders | publisher=Elsevier BV | volume=117 | issue=Suppl 1 | year=2009 | issn=0165-0327 | doi=10.1016/j.jad.2009.06.043 | pages=S1–S64 | pmid=19682750 | url=http://www.canmat.org/resources/CANMAT%20Depression%20Guidelines%202009.pdf | url-status=dead | archive-url=https://web.archive.org/web/20150823230409/http://www.canmat.org/resources/canmat%20depression%20guidelines%202009.pdf | archive-date=23 August 2015 }}</ref> and the Royal Australia and New Zealand College of Psychiatrists have endorsed TMS for trMDD.<ref>{{cite journal |vauthors=Rush AJ, Marangell LB, Sackeim HA, et al |title=Vagus nerve stimulation for treatment-resistant depression: a randomized, controlled acute phase trial |journal=Biological Psychiatry |volume=58 |issue=5 |pages=347–54 |date=September 2005 |pmid=16139580 |doi=10.1016/j.biopsych.2005.05.025|s2cid=22066326 |url=http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1069&context=veterans }}</ref> [[Transcranial direct current stimulation]] (tDCS) is another noninvasive method used to stimulate small regions of the brain with a weak electric current. Several meta-analyses have concluded that active tDCS was useful for treating depression.<ref>{{cite journal |vauthors=Fregni F, El-Hagrassy MM, Pacheco-Barrios K, et al |title=Evidence-Based Guidelines and Secondary Meta-Analysis for the Use of Transcranial Direct Current Stimulation in Neurological and Psychiatric Disorders |journal=Int J Neuropsychopharmacol |volume=24 |issue=4 |pages=256–313 |date=April 2021 |pmid=32710772 |pmc=8059493 |doi=10.1093/ijnp/pyaa051 }}</ref><ref>{{cite journal | vauthors = Moffa AH, Martin D, Alonzo A, et al | title = Efficacy and acceptability of transcranial direct current stimulation (tDCS) for major depressive disorder: An individual patient data meta-analysis | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 99 | pages = 109836 | date = April 2020 | pmid = 31837388 | doi = 10.1016/j.pnpbp.2019.109836 | s2cid = 209373871 }}</ref>
 
 
 
There is a small amount of evidence that [[sleep deprivation]] may improve depressive symptoms in some individuals,<ref>{{cite journal |vauthors=Ioannou M, Wartenberg C, Greenbrook JT, et al |title=Sleep deprivation as treatment for depression: Systematic review and meta-analysis |journal=Acta Psychiatr Scand |volume=143 |issue=1 |pages=22–35 |date=January 2021 |pmid=33145770 |pmc=7839702 |doi=10.1111/acps.13253 }}</ref> with the effects usually showing up within a day. This effect is usually temporary. Besides sleepiness, this method can cause a side effect of [[mania]] or [[hypomania]].<ref>{{cite journal |vauthors=Giedke H, Schwärzler F |title=Therapeutic use of sleep deprivation in depression |journal=Sleep Medicine Reviews |volume=6 |issue=5 |pages=361–77 |date=October 2002 |pmid=12531127 |doi=10.1053/smrv.2002.0235 }}</ref> There is insufficient evidence for [[Reiki]]<ref>{{cite journal | vauthors = Joyce J, Herbison GP | title = Reiki for depression and anxiety | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD006833 | date = April 2015 | pmid = 25835541 | doi = 10.1002/14651858.cd006833.pub2 }}</ref> and [[dance movement therapy]] in depression.<ref>{{cite journal | vauthors = Meekums B, Karkou V, Nelson EA | title = Dance movement therapy for depression | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD009895 | date = February 2015 | volume = 2016 | pmid = 25695871 | doi = 10.1002/14651858.cd009895.pub2 | pmc = 8928931 | url = http://eprints.whiterose.ac.uk/87222/8/Meekums_et_al-2015-The_Cochrane_Library.pdf }}</ref> [[Medical cannabis|Cannabis]] is specifically not recommended as a treatment.<ref>{{cite journal | vauthors = Black N, Stockings E, Campbell G, et al | title = Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis | journal = The Lancet. Psychiatry | volume = 6 | issue = 12 | pages = 995–1010 | date = December 2019 | pmid = 31672337 | pmc = 6949116 | doi = 10.1016/S2215-0366(19)30401-8 }}</ref>
 
  
 
==Prognosis==
 
==Prognosis==
Studies have shown that 80% of those with a first major depressive episode will have at least one more during their life,<ref>{{cite journal |vauthors=Fava GA, Park SK, Sonino N |title=Treatment of recurrent depression |journal=Expert Review of Neurotherapeutics |volume=6 |issue=11 |pages=1735–40 |date=November 2006 |pmid=17144786 |doi=10.1586/14737175.6.11.1735 |s2cid=22808803 }}</ref> with a lifetime average of four episodes.<ref>{{cite journal |vauthors=Limosin F, Mekaoui L, Hautecouverture S |title=[Prophylactic treatment for recurrent major depression] |journal=Presse Médicale |volume=36 |issue=11 Pt 2 |pages=1627–33 |date=November 2007 |pmid=17555914 |doi=10.1016/j.lpm.2007.03.032 }}</ref> Other general population studies indicate that around half those who have an episode recover (whether treated or not) and remain well, while the other half will have at least one more, and around 15% of those experience chronic recurrence.<ref>{{cite journal |vauthors=Eaton WW, Shao H, Nestadt G, et al |title=Population-based study of first onset and chronicity in major depressive disorder |journal=Archives of General Psychiatry |volume=65 |issue=5 |pages=513–20 |date=May 2008 |pmid=18458203 |pmc=2761826 |doi=10.1001/archpsyc.65.5.513 }}</ref> Studies recruiting from selective inpatient sources suggest lower recovery and higher chronicity, while studies of mostly outpatients show that nearly all recover, with a median episode duration of 11 months. Around 90% of those with severe or psychotic depression, most of whom also meet criteria for other mental disorders, experience recurrence.<ref>{{cite journal |vauthors=Holma KM, Holma IA, Melartin TK, Rytsälä HJ, Isometsä ET |title=Long-term outcome of major depressive disorder in psychiatric patients is variable |journal=The Journal of Clinical Psychiatry |volume=69 |issue=2 |pages=196–205 |date=February 2008 |pmid=18251627 |doi=10.4088/JCP.v69n0205 }}</ref><ref>{{cite journal |vauthors=Kanai T, Takeuchi H, Furukawa TA, et al |title=Time to recurrence after recovery from major depressive episodes and its predictors |journal=Psychological Medicine |volume=33 |issue=5 |pages=839–45 |date=July 2003 |pmid=12877398 |doi=10.1017/S0033291703007827 |s2cid=10490348 }}</ref> Cases when outcome is poor are associated with inappropriate treatment, severe initial symptoms including psychosis, early age of onset, previous episodes, incomplete recovery after one year of treatment, pre-existing severe mental or medical disorder, and [[family dysfunction]].<ref>{{cite web|url=http://www.mdguidelines.com/depression-major/prognosis|title=Depression, Major: Prognosis|website=MDGuidelines|publisher=[[The Guardian Life Insurance Company of America]]|access-date=16 July 2010|url-status=live|archive-url=https://web.archive.org/web/20100420055044/http://www.mdguidelines.com/depression-major/prognosis|archive-date=20 April 2010}}</ref>
+
Major depressive episodes often resolve over time, whether or not they are treated. However, the majority of those with a first major depressive episode will have at least one more during their lifetime.
 
 
A high proportion of people who experience full symptomatic remission still have at least one not fully resolved symptom after treatment.<ref name=Culpepper2015>{{cite journal | vauthors = Culpepper L, Muskin PR, Stahl SM | title = Major Depressive Disorder: Understanding the Significance of Residual Symptoms and Balancing Efficacy with Tolerability | journal = The American Journal of Medicine | volume = 128 | issue = 9 Suppl | pages = S1–S15 | date = September 2015 | pmid = 26337210 | doi = 10.1016/j.amjmed.2015.07.001 | doi-access = free }}</ref> Recurrence or chronicity is more likely if symptoms have not fully resolved with treatment.<ref name=Culpepper2015/> Current guidelines recommend continuing antidepressants for four to six&nbsp;months after remission to prevent relapse. Evidence from many [[randomized controlled trial]]s indicates continuing antidepressant medications after recovery can reduce the chance of relapse by 70% (41% on placebo vs. 18% on antidepressant). The preventive effect probably lasts for at least the first 36&nbsp;months of use.<ref>{{cite journal | vauthors = Geddes JR, Carney SM, Davies C, et al | title = Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review | journal = Lancet | volume = 361 | issue = 9358 | pages = 653–61 | date = February 2003 | pmid = 12606176 | doi = 10.1016/S0140-6736(03)12599-8 | s2cid = 20198748 }}</ref>
 
 
 
Major depressive episodes often resolve over time, whether or not they are treated. Outpatients on a waiting list show a 10–15% reduction in symptoms within a few months, with approximately 20% no longer meeting the full criteria for a depressive disorder.<ref>{{cite journal |vauthors=Posternak MA, Miller I |title=Untreated short-term course of major depression: a meta-analysis of outcomes from studies using wait-list control groups |journal=Journal of Affective Disorders |volume=66 |issue=2–3 |pages=139–46 |date=October 2001 |pmid=11578666 |doi=10.1016/S0165-0327(00)00304-9 }}</ref> The [[median]] duration of an episode has been estimated to be 23 weeks, with the highest rate of recovery in the first three months.<ref>{{cite journal |vauthors=Posternak MA, Solomon DA, Leon AC, et al |title=The naturalistic course of unipolar major depression in the absence of somatic therapy |journal=The Journal of Nervous and Mental Disease |volume=194 |issue=5 |pages=324–29 |date=May 2006 |pmid=16699380 |doi=10.1097/01.nmd.0000217820.33841.53 |s2cid=22891687 }}</ref> According to a 2013 review, 23% of untreated adults with mild to moderate depression will remit within 3 months, 32% within 6 months and 53% within 12 months.<ref>{{cite journal | vauthors= Whiteford HA, Harris MG, McKeon G, et al | title=Estimating remission from untreated major depression: a systematic review and meta-analysis | journal=Psychological Medicine | publisher=Cambridge University Press (CUP) | volume=43 | issue=8 | date=10 August 2012 | issn=0033-2917 | pmid=22883473 | doi=10.1017/s0033291712001717 | pages=1569–1585| s2cid=11068930 }}</ref>
 
  
 
===Ability to work===
 
===Ability to work===
Depression may affect people's ability to work. The combination of usual clinical care and support with return to work (like working less hours or changing tasks) probably reduces sick leave by 15%, and leads to fewer depressive symptoms and improved work capacity, reducing sick leave by an annual average of 25 days per year.<ref name=Nieuwenhuijsen2020>{{cite journal |vauthors=Nieuwenhuijsen K, Verbeek JH, Neumeyer-Gromen A, et al |title=Interventions to improve return to work in depressed people |journal=Cochrane Database Syst Rev |volume=10 |issue= 12|pages=CD006237 |date=October 2020 |pmid=33052607 |doi=10.1002/14651858.CD006237.pub4 |pmc=8094165 }}</ref> Helping depressed people return to work without a connection to clinical care has not been shown to have an effect on sick leave days. Additional psychological interventions (such as online cognitive behavioral therapy) lead to fewer sick days compared to standard management only. Streamlining care or adding specific providers for depression care may help to reduce sick leave.<ref name=Nieuwenhuijsen2020/>
+
Depression may affect people's ability to work. The combination of usual clinical care and support with return to work (like working less hours or changing tasks) leads to fewer depressive symptoms and improved work capacity. Additional psychological interventions (such as online cognitive behavioral therapy) as well as streamlining care or adding specific providers for depression care improve ability to work.
  
 
===Life expectancy and the risk of suicide===
 
===Life expectancy and the risk of suicide===
Depressed individuals have a shorter [[life expectancy]] than those without depression, in part because people who are depressed are at risk of dying of suicide.<ref>{{cite journal |vauthors=Cassano P, Fava M |title=Depression and public health: an overview |journal=Journal of Psychosomatic Research |volume=53 |issue=4 |pages=849–57 |date=October 2002 |pmid=12377293 |doi=10.1016/S0022-3999(02)00304-5 }}</ref> Up to 60% of people who die of suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and [[borderline personality disorder]].{{sfn|Barlow|Durand|2005|pp=248–49}} About 2–8% of adults with major depression die by [[suicide]],<ref name=Rich2014/><ref>{{cite book |last1=Strakowski|first1=Stephen |last2=Nelson |first2=Erik |name-list-style=vanc |title=Major Depressive Disorder |date=2015 |publisher=Oxford University Press |isbn=978-0-19-026432-1 |page=PT27 |url=https://books.google.com/books?id=nD8FCgAAQBAJ&pg=PT27 }}</ref> and about 50% of people who die by suicide had depression or another [[mood disorder]].<ref>{{cite journal |vauthors=Bachmann S |title=Epidemiology of Suicide and the Psychiatric Perspective |journal=International Journal of Environmental Research and Public Health |date=6 July 2018 |volume=15 |issue=7 |page=1425 |doi=10.3390/ijerph15071425 |pmid=29986446|pmc=6068947 |quote=Half of all completed suicides are related to depressive and other mood disorders|doi-access=free }}</ref> The lifetime risk of suicide associated with a diagnosis of major depression in the US is estimated at 3.4%, which averages two highly disparate figures of almost 7% for men and 1% for women<ref>{{cite journal |vauthors=Blair-West GW, Mellsop GW |title=Major depression: does a gender-based down-rating of suicide risk challenge its diagnostic validity? |journal=The Australian and New Zealand Journal of Psychiatry |volume=35 |issue=3 |pages=322–28 |date=June 2001 |pmid=11437805 |doi=10.1046/j.1440-1614.2001.00895.x |s2cid=36975913 }}</ref> (although suicide attempts are more frequent in women).<ref>{{cite journal |vauthors=Oquendo MA, Bongiovi-Garcia ME, Galfalvy H, et al |title=Sex differences in clinical predictors of suicidal acts after major depression: a prospective study |journal=The American Journal of Psychiatry |volume=164 |issue=1 |pages=134–41 |date=January 2007 |pmid=17202555 |pmc=3785095 |doi=10.1176/ajp.2007.164.1.134 }}</ref> The estimate is substantially lower than a previously accepted figure of 15%, which had been derived from older studies of people who were hospitalized.<ref>{{cite journal |vauthors=Bostwick JM, Pankratz VS |title=Affective disorders and suicide risk: a reexamination |journal=The American Journal of Psychiatry |volume=157 |issue=12 |pages=1925–32 |date=December 2000 |pmid=11097952 |doi=10.1176/appi.ajp.157.12.1925}}</ref>
+
Depressed individuals have a shorter [[life expectancy]] than those without depression, in part because people who are depressed are at risk of dying of [[suicide]]. Approximately half the people who die of suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and [[borderline personality disorder]].<ref name=Barlow/><ref> Stephen Strakowski and Erik Nelson,  ''Major Depressive Disorder'' (Oxford University Press, 2015, ISBN 978-0190206185) </ref>  
  
Depressed people have a higher [[mortality rate|rate of dying]] from other causes.<ref>{{cite journal |vauthors=Rush AJ |title=The varied clinical presentations of major depressive disorder |journal=The Journal of Clinical Psychiatry |volume=68 |issue=Supplement 8 |pages=4–10 |year=2007 |pmid=17640152 }}</ref> There is a 1.5- to 2-fold increased risk of [[cardiovascular disease]], independent of other known risk factors, and is itself linked directly or indirectly to risk factors such as smoking and obesity. People with major depression are less likely to follow medical recommendations for treating and preventing [[cardiovascular disorders]], further increasing their risk of medical complications.<ref>{{cite journal |vauthors=Swardfager W, Herrmann N, Marzolini S, et al |title=Major depressive disorder predicts completion, adherence, and outcomes in cardiac rehabilitation: a prospective cohort study of 195 patients with coronary artery disease |journal=The Journal of Clinical Psychiatry |volume=72 |issue=9 |pages=1181–88 |date=September 2011 |pmid=21208573 |doi=10.4088/jcp.09m05810blu}}</ref> [[Cardiologists]] may not recognize underlying depression that complicates a cardiovascular problem under their care.<ref>{{cite journal|vauthors=Schulman J, Shapiro BA|year=2008|journal=Psychiatric Times|volume=25|issue=9|title=Depression and Cardiovascular Disease: What Is the Correlation?|url=http://www.psychiatrictimes.com/depression/article/10168/1171821|access-date=10 June 2009|archive-date=6 March 2020|archive-url=https://web.archive.org/web/20200306051101/http://www.psychiatrictimes.com/depression/article/10168/1171821|url-status=dead}}</ref>
+
Those suffering from major depression also have a higher [[mortality rate|rate of dying]] from other causes. People with major depression are at risk death from [[cardiovascular disease]], especially since they less likely to follow medical recommendations for its treatment and prevention, further increasing their risk of medical complications.
  
 
==Epidemiology==
 
==Epidemiology==
 +
Major depressive disorder affects millions of people throughout the world. Women are more affected than men, although although it is unclear why this is so.
  
Major depressive disorder affects millions of people throughout the world.
+
People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60.<ref>W.W. Eaton et al, Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up] ''Archives of General Psychiatry'' 54(11) (November 1997): 993–999. Retrieved October 17, 2022.</ref> The risk of major depression is increased with neurological conditions such as [[stroke]], [[Parkinson's disease]], or [[multiple sclerosis]], and during the first year after childbirth.<ref>Hugh Rickards, [https://jnnp.bmj.com/content/76/suppl_1/i48 Depression in neurological disorders: Parkinson's disease, multiple sclerosis, and stroke] ''Journal of Neurology, Neurosurgery, and Psychiatry'' 76(Suppl 1) (March 2005): i48–52. Retrieved October 17, 2022. </ref>
 +
 +
===Comorbidity===
 +
Major depression frequently [[Comorbidity|co-occurs]] with other psychiatric problems, as well as increased rates of [[alcohol]] and [[drug abuse]]. For example, [[Post-traumatic stress disorder]] and depression often co-occur.<ref name=NIMHPub/> Depression often occurs in individuals with [[attention deficit hyperactivity disorder]] (ADHD), complicating the diagnosis and treatment of both.<ref> Edward M. Hallowell and John J. Ratey, ''Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder'' (Ballantine Books, 2005, ISBN 978-0345442314).</ref>
  
In the United States, 8.4% of adults (21&nbsp;million individuals) have at least one episode within a year-long period; the probability of having a major depressive episode is higher for females than males (10.5% to 6.2%), and highest for those aged 18 to 25 (17%).<ref name= NIMHMajorDepression>{{cite web |url= https://www.nimh.nih.gov/health/statistics/major-depression |publisher= U.S. [[National Institute of Mental Health]] (NIMH) |date= January 2022 |title= Major depression |archive-url=https://web.archive.org/web/20220809144808/https://www.nimh.nih.gov/health/statistics/major-depression |archive-date= 9 August 2022 |access-date= 14 August 2022}} {{Pd-notice}}</ref> Among adolescents between the ages of 12 and 17, 17% of the U.S. population (4.1&nbsp;million individuals) had a major depressive episode in 2020 (females 25.2%, males 9.2%).<ref name= NIMHMajorDepression/> Among individuals reporting two or more races, the US prevalence is highest.<ref name=NIMHMajorDepression/>
+
[[Anxiety disorder|anxiety]] symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability, and increased suicidal behavior.<ref>Robert M.A. Hirschfeld, [https://pubmed.ncbi.nlm.nih.gov/15014592/ The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care]  ''Primary Care Companion to the Journal of Clinical Psychiatry'' 3(6) (December 2001): 244–254. Retrieved October 18, 2022.</ref>  
  
Major depression is about twice as common in women as in men, although it is unclear why this is so, and whether factors unaccounted for are contributing to this.<ref name=Kuehner03>{{cite journal |vauthors=Kuehner C |title=Gender differences in unipolar depression: an update of epidemiological findings and possible explanations |journal=Acta Psychiatrica Scandinavica |volume=108 |issue=3 |pages=163–74 |date=September 2003 |pmid=12890270 |doi=10.1034/j.1600-0447.2003.00204.x |s2cid=19538251 }}</ref> The relative increase in occurrence is related to pubertal development rather than chronological age, reaches adult ratios between the ages of 15 and 18, and appears associated with psychosocial more than hormonal factors.<ref name=Kuehner03 /> In 2019, major depressive disorder was identified (using either the DSM-IV-TR or ICD-10) in the [[Global Burden of Disease Study]] as the fifth most common cause of [[years lived with disability]] and the 18th most common for [[disability-adjusted life years]].<ref>{{citation |author=Institute for Health Metrics and Evaluation |author-link=Institute for Health Metrics and Evaluation |year=2020 |title=Global Burden of Disease 2019 Cause and Risk Summary: Major depressive disorder — Level 4 cause |at=Table 3 |url=https://www.healthdata.org/results/gbd_summaries/2019/major-depressive-disorder-level-4-cause |publisher=University of Washington |place=Seattle, USA |access-date=9 July 2022}}</ref><!-- the wording of this sentence is very janky, but this best mimics the source. —>
+
Depression and [[pain]] often co-occur, although it is under-recognized, and therefore under-treated, in patients presenting with pain. Depression often coexists with physical disorders common among the elderly, such as [[stroke]], other [[cardiovascular diseases]], [[Parkinson's disease]], and [[chronic obstructive pulmonary disease]].
  
People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60.<ref>{{cite journal |vauthors=Eaton WW, Anthony JC, Gallo J, et al |title=Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up |journal=Archives of General Psychiatry |volume=54 |issue=11 |pages=993–99 |date=November 1997 |pmid=9366655 |doi=10.1001/archpsyc.1997.01830230023003 }}</ref> The risk of major depression is increased with neurological conditions such as [[stroke]], [[Parkinson's disease]], or [[multiple sclerosis]], and during the first year after childbirth.<ref>{{cite journal |vauthors=Rickards H |title=Depression in neurological disorders: Parkinson's disease, multiple sclerosis, and stroke |journal=Journal of Neurology, Neurosurgery, and Psychiatry |volume=76 |issue=Suppl 1 |pages=i48–52 |date=March 2005 |pmid=15718222 |pmc=1765679 |doi=10.1136/jnnp.2004.060426}}</ref> It is also more common after cardiovascular illnesses, and is related more to those with a poor cardiac [[Prognosis|disease outcome]] than to a better one.<ref>{{cite journal |vauthors=Alboni P, Favaron E, Paparella N, Sciammarella M, Pedaci M |title=Is there an association between depression and cardiovascular mortality or sudden death? |journal=Journal of Cardiovascular Medicine |volume=9 |issue=4 |pages=356–62 |date=April 2008 |pmid=18334889 |doi=10.2459/JCM.0b013e3282785240 |s2cid=11051637 }}</ref><ref>{{cite journal |vauthors=Strik JJ, Honig A, Maes M |title=Depression and myocardial infarction: relationship between heart and mind |journal=Progress in Neuro-Psychopharmacology & Biological Psychiatry |volume=25 |issue=4 |pages=879–92 |date=May 2001 |pmid=11383983 |doi=10.1016/S0278-5846(01)00150-6 |s2cid=45722423 }}</ref> Depressive disorders are more common in urban populations than in rural ones and the prevalence is increased in groups with poorer socioeconomic factors, e.g., homelessness.<ref>Gelder, M, Mayou, R and Geddes, J (2005). ''Psychiatry''. 3rd ed. New York: Oxford. p. 105.</ref> Depression is common among those over 65 years of age and increases in frequency beyond this age.<ref name="SBU">{{Cite web |author=[[Swedish Agency for Health Technology Assessment and Assessment of Social Services]] (SBU) |date=27 January 2015 |title=Depression treatment for the elderly |url=http://www.sbu.se/en/publications/sbu-assesses/depression-treatment-for-the-elderly/ |url-status=live |archive-url=https://web.archive.org/web/20160618011954/http://www.sbu.se/en/publications/sbu-assesses/depression-treatment-for-the-elderly/ |archive-date=18 June 2016 |access-date=16 June 2016 |website=sbu.se}}</ref> The risk of depression increases in relation to the frailty of the individual.<ref>{{cite journal |vauthors=Soysal P, Veronese N, Thompson, et al |date=July 2017 |title=Relationship between depression and frailty in older adults: A systematic review and meta-analysis |url=http://www.repositorio.ufc.br/handle/riufc/25064 |journal=Ageing Res Rev |volume=36 |pages=78–87 |doi=10.1016/j.arr.2017.03.005 |pmid=28366616 |s2cid=205668529}}</ref> Depression is one of the most important factors which negatively impact quality of life in adults, as well as the elderly.<ref name="SBU" /> Both symptoms and treatment among the elderly differ from those of the rest of the population.<ref name="SBU" />
+
==Social stigma==
 
+
Historical figures were often reluctant to discuss or seek treatment for depression due to [[social stigma]] about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. People who may have had depression include English author [[Mary Shelley]],<ref>Miranda Seymour, ''Mary Shelley'' (Grove Press, 2002, ISBN 978-0802139481).</ref> American-British writer [[Henry James]],<ref> Leon Edel (ed.), ''The Letters of Henry James 1883–1895'' (Belknap Press, 1980, ISBN 978-0674387829).</ref> and American president [[Abraham Lincoln]].<ref>Michael Burlingame, ''The Inner World of Abraham Lincoln'' (University of Illinois Press, 1997, ISBN 978-0252066672).</ref>  
Major depression was the leading cause of [[disease burden]] in North America and other high-income countries, and the fourth-leading cause worldwide as of 2006. In the year 2030, it is predicted to be the second-leading cause of disease burden worldwide after [[HIV]], according to the WHO.<ref>{{cite journal |vauthors=Mathers CD, Loncar D |title=Projections of global mortality and burden of disease from 2002 to 2030 |journal=PLOS Medicine |volume=3 |issue=11 |page=e442 |date=November 2006 |pmid=17132052 |pmc=1664601 |doi=10.1371/journal.pmed.0030442 }}</ref> Delay or failure in seeking treatment after relapse and the failure of health professionals to provide treatment are two barriers to reducing disability.<ref>{{cite journal |vauthors=Andrews G |title=Reducing the burden of depression |journal=Canadian Journal of Psychiatry |volume=53 |issue=7 |pages=420–27 |date=July 2008 |pmid=18674396 |doi=10.1177/070674370805300703|doi-access=free }}</ref>
 
 
 
===Comorbidity===
 
Major depression frequently [[Comorbidity|co-occurs]] with other psychiatric problems. The 1990–92 ''[[National Comorbidity Survey]]'' (US) reported that half of those with major depression also have lifetime [[anxiety]] and its associated disorders, such as [[generalized anxiety disorder]].<ref>{{cite journal |vauthors=Kessler RC, Nelson CB, McGonagle KA, et al|title=Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey |journal=The British Journal of Psychiatry. Supplement |volume=168 |issue=30 |pages=17–30 |date=June 1996 |pmid=8864145 |doi=10.1192/S0007125000298371 |s2cid=19525295 }}</ref> Anxiety symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability and increased suicidal behavior.<ref>{{cite journal |vauthors=Hirschfeld RM |title=The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care |journal=Primary Care Companion to the Journal of Clinical Psychiatry |volume=3 |issue=6 |pages=244–54 |date=December 2001 |pmid=15014592 |pmc=181193 |doi=10.4088/PCC.v03n0609 }}</ref> Depressed people have increased rates of alcohol and substance use, particularly dependence,<ref>{{cite journal |vauthors=Grant BF |title=Comorbidity between DSM-IV drug use disorders and major depression: results of a national survey of adults |journal=Journal of Substance Abuse |volume=7 |issue=4 |pages=481–97 |year=1995 |pmid=8838629 |doi=10.1016/0899-3289(95)90017-9 }}</ref><ref>{{cite journal | vauthors = Boden JM, Fergusson DM | title = Alcohol and depression | journal = Addiction | volume = 106 | issue = 5 | pages = 906–14 | date = May 2011 | pmid = 21382111 | doi = 10.1111/j.1360-0443.2010.03351.x | hdl = 10523/10319 | hdl-access = free }}</ref> and around a third of individuals diagnosed with [[attention deficit hyperactivity disorder]] (ADHD) develop comorbid depression.<ref>{{cite book |title=Delivered from distraction: Getting the most out of life with Attention Deficit Disorder |url=https://archive.org/details/deliveredfromdis00edwa |url-access=registration |vauthors=Hallowell EM, Ratey JJ |year=2005 |publisher=Ballantine Books |location=New York|isbn=978-0-345-44231-4 |pages=[https://archive.org/details/deliveredfromdis00edwa/page/253 253–55]}}</ref> [[Post-traumatic stress disorder]] and depression often co-occur.<ref name=NIMHPub/> Depression may also coexist with ADHD, complicating the diagnosis and treatment of both.<ref>{{cite journal |vauthors=Brunsvold GL, Oepen G |title=Comorbid Depression in ADHD: Children and Adolescents |journal=Psychiatric Times |volume=25 |issue=10 |year=2008 |url=http://www.psychiatrictimes.com/adhd/article/10168/1286863 |url-status=live |archive-url=https://web.archive.org/web/20090524050341/http://www.psychiatrictimes.com/adhd/article/10168/1286863 |archive-date=24 May 2009 }}</ref> Depression is also frequently comorbid with [[alcohol use disorder]] and [[personality disorder]]s.<ref>{{cite journal |vauthors=Melartin TK, Rytsälä HJ, Leskelä US, Lestelä-Mielonen PS, Sokero TP, Isometsä ET |title=Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study |journal=The Journal of Clinical Psychiatry |volume=63 |issue=2 |pages=126–34 |date=February 2002 |pmid=11874213 |doi=10.4088/jcp.v63n0207 }}</ref> Depression can also be exacerbated during particular months (usually winter) in those with [[seasonal affective disorder]]. While [[Digital media use and mental health|overuse of digital media]] has been associated with depressive symptoms, using digital media may also improve mood in some situations.<ref>{{cite journal | vauthors = Hoge E, Bickham D, Cantor J | title = Digital Media, Anxiety, and Depression in Children | journal = Pediatrics | volume = 140 | issue = Suppl 2 | pages = S76–S80 | date = November 2017 | pmid = 29093037 | doi = 10.1542/peds.2016-1758G | url = https://pediatrics.aappublications.org/content/140/Supplement_2/S76 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Elhai JD, Dvorak RD, Levine JC, Hall BJ | title = Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology | journal = Journal of Affective Disorders | volume = 207 | pages = 251–259 | date = January 2017 | pmid = 27736736 | doi = 10.1016/j.jad.2016.08.030 | s2cid = 205642153 }}</ref>
 
 
 
Depression and [[pain]] often co-occur. One or more pain symptoms are present in 65% of people who have depression, and anywhere from 5 to 85% of people who are experiencing pain will also have depression, depending on the setting—a lower prevalence in general practice, and higher in specialty clinics. Depression is often underrecognized, and therefore undertreated, in patients presenting with pain.<ref>{{cite journal |vauthors=Bair MJ, Robinson RL, Katon W, Kroenke K |title=Depression and pain comorbidity: a literature review |journal=Archives of Internal Medicine |volume=163 |issue=20 |pages=2433–45 |date=November 2003 |pmid=14609780 |doi=10.1001/archinte.163.20.2433 |url=http://archinte.ama-assn.org/cgi/content/full/163/20/2433(fulltext) |doi-access=free }}</ref> Depression often coexists with physical disorders common among the elderly, such as [[stroke]], other [[cardiovascular diseases]], [[Parkinson's disease]], and [[chronic obstructive pulmonary disease]].<ref>{{cite journal|vauthors=Yohannes AM, Baldwin RC|title=Medical Comorbidities in Late-Life Depression|journal=Psychiatric Times|volume=25|issue=14|year=2008|url=http://www.psychiatrictimes.com/depression/article/10168/1358135|access-date=10 June 2009|archive-date=14 June 2020|archive-url=https://web.archive.org/web/20200614095605/https://www.psychiatrictimes.com/10168/1358135|url-status=dead}}</ref>
 
  
==Social stigma==
+
Some pioneering psychologists, such as Americans [[William James]]<ref>William James, ''Letters of William James'' (Kessinger Publishing, LLC, 2003, ISBN 978-0766175662)</ref> and [[John B. Watson]],<ref>David Cohen, ''J.B. Watson: The Founder of Behaviourism'' (Routledge Kegan & Paul, 1979, ISBN 978-0710000545).</ref> dealt with their own depression.
Historical figures were often reluctant to discuss or seek treatment for depression due to [[social stigma]] about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. People who may have had depression include English author [[Mary Shelley]],<ref>{{cite book |last=Seymour|first=Miranda |name-list-style=vanc |title=Mary Shelley|publisher=Grove Press|year=2002 |pages=560–61 |isbn=978-0-8021-3948-1}}</ref> American-British writer [[Henry James]],<ref>{{cite web|url=https://www.pbs.org/wgbh/masterpiece/americancollection/american/genius/henry_bio.html|title=Biography of Henry James|publisher=[[Public Broadcasting Service|PBS]]|access-date=19 August 2008|url-status=dead|archive-url=https://web.archive.org/web/20081008042925/http://www.pbs.org/wgbh/masterpiece/americancollection/american/genius/henry_bio.html|archive-date=8 October 2008}}</ref> and American president [[Abraham Lincoln]].<ref>{{cite book |last=Burlingame |first=Michael |name-list-style=vanc |title=The Inner World of Abraham Lincoln |publisher=University of Illinois Press |location=Urbana |year=1997 |isbn=978-0-252-06667-2 |pages=xvii, 92–113 }}</ref> Some well-known contemporary people with possible depression include Canadian songwriter [[Leonard Cohen]]<ref>{{cite web |author=Pita E |url=http://www.webheights.net/10newsongs/press/elmunmag.htm |title=An Intimate Conversation with...Leonard Cohen |date=26 September 2001 |access-date=3 October 2008 |url-status=live |archive-url=https://web.archive.org/web/20081011082500/http://www.webheights.net/10newsongs/press/elmunmag.htm |archive-date=11 October 2008 }}</ref> and American playwright and novelist [[Tennessee Williams]].<ref>{{cite journal |vauthors=Jeste ND, Palmer BW, Jeste DV |title=Tennessee Williams |journal=The American Journal of Geriatric Psychiatry |volume=12 |issue=4 |pages=370–75 |year=2004 |pmid=15249274 |doi=10.1097/00019442-200407000-00004 }}</ref> Some pioneering psychologists, such as Americans [[William James]]<ref>{{cite book |vauthors=James H |title=Letters of William James (Vols. 1 and 2) |publisher=Kessinger Publishing Co|location=Montana |pages=147–48|isbn=978-0-7661-7566-2 |year=1920}}</ref><ref name="HistoryJames">{{Harvnb |Hergenhahn|2005|p=311}}</ref> and [[John B. Watson]],<ref>{{cite book |vauthors=Cohen D |title=J. B. Watson: The Founder of Behaviourism |publisher=Routledge & Kegan Paul |location=London |year=1979 |page=7 |isbn=978-0-7100-0054-5}}</ref> dealt with their own depression.
 
  
Social stigma of major depression is widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly.<ref>{{cite book |title=Unmet Need in Psychiatry:Problems, Resources, Responses |veditors=Andrews G, Henderson S |year=2000 |publisher=Cambridge University Press |page=[https://archive.org/details/unmetneedinpsych0000unse/page/409 409] |chapter=Public knowledge of and attitudes to mental disorders: a limiting factor in the optimal use of treatment services |vauthors=Jorm AF, Angermeyer M, Katschnig H |isbn=978-0-521-66229-1 |chapter-url=https://archive.org/details/unmetneedinpsych0000unse/page/409 }}</ref> In the UK, the [[Royal College of Psychiatrists]] and the [[Royal College of General Practitioners]] conducted a joint Five-year Defeat Depression campaign to educate and reduce stigma from 1992 to 1996;<ref>{{cite journal |vauthors=Paykel ES, Tylee A, Wright A, et al |title=The Defeat Depression Campaign: psychiatry in the public arena |journal=The American Journal of Psychiatry |volume=154 |issue=6 Suppl |pages=59–65 |date=June 1997 |pmid=9167546 |doi=10.1176/ajp.154.6.59 |doi-access=free }}</ref> a [[Ipsos MORI|MORI]] study conducted afterwards showed a small positive change in public attitudes to depression and treatment.<ref>{{cite journal |vauthors=Paykel ES, Hart D, Priest RG |title=Changes in public attitudes to depression during the Defeat Depression Campaign |journal=The British Journal of Psychiatry |volume=173 |issue=6 |pages=519–22 |date=December 1998 |pmid=9926082 |doi=10.1192/bjp.173.6.519 |s2cid=21172113 }}</ref>
+
Social stigma of major depression continues to  be widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly.<ref>Gavin Andrews and Scott Henderson (eds.), ''Unmet Need in Psychiatry: Problems, Resources, Responses'' (Cambridge University Press, 2006, ISBN 978-0521027236).</ref>
  
 
==Notes==
 
==Notes==
Line 208: Line 182:
  
 
* American Psychiatric Association. ''Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5''. American Psychiatric Publishing, Inc., 2013. ISBN 978-0890425558  
 
* American Psychiatric Association. ''Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5''. American Psychiatric Publishing, Inc., 2013. ISBN 978-0890425558  
 +
* Andrews, Gavin, and Scott Henderson (eds.). ''Unmet Need in Psychiatry: Problems, Resources, Responses''. Cambridge University Press, 2006. ISBN 978-0521027236
 +
* Barlow, David H., Vincent Mark Durand, and Stefan G. Hofmann. ''Abnormal Psychology: An Integrative Approach (8th edition)''. Cengage Learning, 2017. ISBN 978-1305950443
 
* Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. ''Cognitive Therapy of Depression''. The Guilford Press, 1987. ISBN 978-0898629194
 
* Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. ''Cognitive Therapy of Depression''. The Guilford Press, 1987. ISBN 978-0898629194
 
* Blazer, Dan G. ''The Age of Melancholy: "Major Depression" and its Social Origin''. Routledge, 2005. ISBN 978-0415951883
 
* Blazer, Dan G. ''The Age of Melancholy: "Major Depression" and its Social Origin''. Routledge, 2005. ISBN 978-0415951883
 +
* Burlingame, Michael. ''The Inner World of Abraham Lincoln''. University of Illinois Press, 1997. ISBN 978-0252066672
 +
* Cohen, David. ''J.B. Watson: The Founder of Behaviourism''. Routledge Kegan & Paul, 1979. ISBN 978-0710000545
 
* Committee on Nomenclature and Statistics of the American Psychiatric Association. ''Diagnostic and statistical manual of mental disorders: DSM-II''. American Psychiatric Association, 1968. {{ASIN|B0030A4JAE}}
 
* Committee on Nomenclature and Statistics of the American Psychiatric Association. ''Diagnostic and statistical manual of mental disorders: DSM-II''. American Psychiatric Association, 1968. {{ASIN|B0030A4JAE}}
 +
* Edel, Leon (ed.). ''The Letters of Henry James 1883–1895''. Belknap Press, 1980. ISBN 978-0674387829
 
* Eyers, Kerrie (ed.). ''Tracking the Black Dog''. University of New South Wales, 2006. ISBN 978-0868408125
 
* Eyers, Kerrie (ed.). ''Tracking the Black Dog''. University of New South Wales, 2006. ISBN 978-0868408125
 
* Freud, Sigmund. ''On Murder, Mourning, and Melancholia''. Penguin Classic, 2005. ISBN 978-0141183794
 
* Freud, Sigmund. ''On Murder, Mourning, and Melancholia''. Penguin Classic, 2005. ISBN 978-0141183794
 +
* Hallowell, Edward M., and John J. Ratey. ''Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder''. Ballantine Books, 2005. ISBN 978-0345442314
 
* Hankin, Benjamin L., and John R.Z. Abela. ''Development of Psychopathology: A Vulnerability-Stress Perspective''. SAGE Publications, Inc, 2005. ISBN 1412904900
 
* Hankin, Benjamin L., and John R.Z. Abela. ''Development of Psychopathology: A Vulnerability-Stress Perspective''. SAGE Publications, Inc, 2005. ISBN 1412904900
 
* Heffernan, Carol F. ''The Melancholy Muse: Chaucer, Shakespeare and Early Medicine''. Duquesne University Press, 1995. ISBN 978-0820702629
 
* Heffernan, Carol F. ''The Melancholy Muse: Chaucer, Shakespeare and Early Medicine''. Duquesne University Press, 1995. ISBN 978-0820702629
 +
* James, William. ''Letters of William James''. Kessinger Publishing, LLC, 2003. ISBN 978-0766175662
 
* Licinio, Julio, and Ma-Li Wong (eds.). ''Biology of Depression: From Novel Insights to Therapeutic Strategies''. Wiley-Blackwell, 2005. ISBN 3527307850
 
* Licinio, Julio, and Ma-Li Wong (eds.). ''Biology of Depression: From Novel Insights to Therapeutic Strategies''. Wiley-Blackwell, 2005. ISBN 3527307850
 
* Mill, John Stuart. ''Autobiography''. Adamant Media Corporation, 2000. ISBN 978-1421242002
 
* Mill, John Stuart. ''Autobiography''. Adamant Media Corporation, 2000. ISBN 978-1421242002
 +
* National Collaborating Centre for Mental Health (NCCMH). ''Depression: The NICE Guideline on the Treatment and Management of Depression in Adults''. RCPsych Publications, 2010. ISBN 978-1904671855
 
* Patton, Lauren L., and Michael Glick (eds.). ''The ADA Practical Guide to Patients with Medical Conditions 2nd Edition''. Wiley-Blackwell, 2015. ISBN 978-1118924402
 
* Patton, Lauren L., and Michael Glick (eds.). ''The ADA Practical Guide to Patients with Medical Conditions 2nd Edition''. Wiley-Blackwell, 2015. ISBN 978-1118924402
 
* Richards, C. Steven, and Michael W. O'Hara (eds.). ''The Oxford Handbook of Depression and Comorbidity''. Oxford University Press, 2014. ISBN 978-0199797004
 
* Richards, C. Steven, and Michael W. O'Hara (eds.). ''The Oxford Handbook of Depression and Comorbidity''. Oxford University Press, 2014. ISBN 978-0199797004
 
* Rosqvist, Johan, and Michel Hersen (eds.). ''Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults''. Wiley, 2007. ISBN 978-0471779995
 
* Rosqvist, Johan, and Michel Hersen (eds.). ''Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults''. Wiley, 2007. ISBN 978-0471779995
 +
* Seymour, Miranda. ''Mary Shelley''. Grove Press, 2002. ISBN 978-0802139481
 
* Wolpert, Lewis. ''Malignant Sadness: The Anatomy of Depression''. Free Press, 2000. ISBN 978-0684870588
 
* Wolpert, Lewis. ''Malignant Sadness: The Anatomy of Depression''. Free Press, 2000. ISBN 978-0684870588
 
 
* {{cite book |title=Diagnostic and statistical manual of mental disorders |edition=Fourth Edition, Text Revision: DSM-IV-TR |publisher=American Psychiatric Publishing, Inc. |location=Washington, DC |year=2000a|isbn=978-0-89042-025-6 |author=American Psychiatric Association}}
 
* {{cite book |title=|publisher= |location=Washington, DC |year=|isbn=978-0-89042-555-8 |author=}}
 
* {{cite book |vauthors=Barlow DH, Durand VM |title=Abnormal psychology: An integrative approach |edition=5th |publisher=Thomson Wadsworth |location=Belmont, CA |year=2005 |isbn=978-0-534-63356-1 }}
 
* {{cite book |vauthors=Beck AT, Rush J, Shaw BF, Emery G |title=Cognitive therapy of depression |publisher=Guilford Press |location=New York|year=1987|orig-year=1979 |isbn=978-0-89862-919-4}}
 
* {{cite book |author=Hergenhahn BR|title=An Introduction to the History of Psychology |edition=5th |publisher=Thomson Wadsworth |location=Belmont, CA |year=2005|isbn=978-0-534-55401-9|ref=CITEREFHergenhahn2005}}
 
* {{cite book |veditors=Parker G, Hadzi-Pavlovic D |title=Melancholia: a disorder of movement and mood: a phenomenological and neurobiological review |publisher=Cambridge University Press |location=Cambridge |year=1996 |isbn=978-0-521-47275-3|ref=CITEREFParker1996}}
 
* {{cite book |title=British National Formulary (BNF 56) |author=Royal Pharmaceutical Society of Great Britain |year=2008 |publisher=BMJ Group and RPS Publishing |location=UK |isbn=978-0-85369-778-7 |url=https://archive.org/details/britishnationalf0000unse_k4e9 |url-access=registration }}
 
* {{cite book |last1=Sadock |first1=Virginia A |last2=Sadock |first2=Benjamin J |last3=Kaplan |first3=Harold I |name-list-style=vanc |title=Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry |publisher=Lippincott Williams & Wilkins |location=Philadelphia |year=2003 |isbn=978-0-7817-3183-6|ref=CITEREFSadock2002}}
 
* {{cite encyclopedia |title=6A70 Single episode depressive disorder |date=February 2022<!-- The most recent update as of the access date —> |orig-date=adopted in 2019<!-- This is when it was adopted by the World Health Assembly —> |url=https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/578635574 |encyclopedia=International Classification of Diseases 11th Revision |publisher=World Health Organization |access-date=9 July 2022 |ref=CITEREF-ICD11-6A70 }}
 
* {{cite encyclopedia |title=6A71 Recurrent depressive disorder |date=February 2022<!-- The most recent update as of the access date —> |orig-date=adopted in 2019<!-- This is when it was adopted by the World Health Assembly —> |url=https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/578635574 |encyclopedia=International Classification of Diseases 11th Revision |publisher=World Health Organization |access-date=9 July 2022 |ref=CITEREF-ICD11-6A71 }}
 
  
 
==External links==
 
==External links==
All links retrieved
+
All links retrieved October 18, 2022.
  
 
* [https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/clinical-depression/faq-20057770 Clinical depression: What does that mean?] ''Mayo Clinic''
 
* [https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/clinical-depression/faq-20057770 Clinical depression: What does that mean?] ''Mayo Clinic''

Revision as of 16:19, 18 October 2022

Clinical depression
Vincent Willem van Gogh 002.jpg
Other namesMajor depressive disorder, major depression, unipolar depression, unipolar disorder, recurrent depression
Sorrowing Old Man (At Eternity's Gate)
by Vincent van Gogh (1890)
SymptomsLow mood, low self-esteem, loss of interest in normally enjoyable activities, low energy, pain without a clear cause[1]
ComplicationsSelf-harm, suicide[2]
Usual onset20s[3]
Duration> 2 weeks[1]
CausesEnvironmental (adverse life experiences, stressful life events), genetic and psychological factors[3]
Risk factorsFamily history, major life changes, certain medications, chronic health problems, substance use disorder[1][3]
Differential diagnosisBipolar disorder, ADHD, sadness[3]
TreatmentPsychotherapy, antidepressant medication, electroconvulsive therapy, exercise[1]
MedicationAntidepressants

Clinical Depression, also known as Major Depressive Disorder (MDD), is a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities over a protracted period of time.

The diagnosis of major depressive disorder is based on the person's reported experiences, behavior reported by relatives or friends, and a mental status examination. The course of the disorder varies widely, from one episode lasting months to a lifelong disorder with recurrent major depressive episodes. Major depressive disorder is believed to be caused by a combination of genetic, environmental, and psychological factors. Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance use disorders. Those suffering from clinical depression are typically treated with psychotherapy and antidepressant medication.

Despite efforts to educate the public about mental disorders, social stigma continues to make it difficult both for those suffering from serious depression to admit their problems and for health professionals to diagnose and treat them. The view held by some psychiatrists that such depression is merely a social construct or imagined illness that is inappropriately regarded as an actual disease compounds these difficulties. Compassion as well as support for effective treatment is needed to allow those suffering from depression to receive appropriate and effective treatment so that they may be successful members of society.

Terminology

The 16th American president, Abraham Lincoln, had "melancholy", a condition that now may be referred to as "clinical depression."[4]

Clinical depression, also known as Major depressive disorder (MDD), is classified as a mental disorder. However, the term "depression" is used in a number of different ways. It is often used to mean the syndrome but may refer to other mood disorders or simply to a low mood. People's conceptualizations of depression vary widely: "Because of the lack of scientific certainty," one commentator has observed, "the debate over depression turns on questions of language. What we call it—'disease,' 'disorder,' 'state of mind'—affects how we view, diagnose, and treat it."[5]

History

Diagnoses of depression go back at least as far as Hippocrates.

The Ancient Greek physician Hippocrates described a syndrome of melancholia (μελαγχολία, melankholía) as a distinct disease with particular mental and physical symptoms; he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment.[6] It was a similar but far broader concept than today's depression; prominence was given to a clustering of the symptoms of sadness, dejection, and despondency, and often fear, anger, delusions, and obsessions were included.[7]

The term "depression" was derived from the Latin verb deprimere, meaning "to press down."[8] From the fourteenth century, "to depress" meant to subjugate or to bring down in spirits. It was used in 1665 in English author Richard Baker's Chronicle to refer to someone having "a great depression of spirit," and by English author Samuel Johnson in a similar sense in 1753.[9] An early usage referring to a psychiatric symptom was by French psychiatrist Louis Delasiauve in 1856, and by the 1860s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function.[10] Since Aristotle, melancholia had been associated with men of learning and intellectual brilliance, a hazard of contemplation and creativity. The newer concept abandoned these associations and through the nineteenth century, and became more associated with women.[7]

Although "melancholia" remained the dominant diagnostic term, "depression" gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist Emil Kraepelin may have been the first to use it as the overarching term, referring to different kinds of melancholia as "depressive states."[9] Freud likened the state of melancholia to mourning in his 1917 paper Mourning and Melancholia. He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious, narcissistic process called the "libidinal cathexis" of the ego. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised.[11] He also emphasized early life experiences as a predisposing factor.[7] Adolf Meyer put forward a mixed social and biological framework emphasizing reactions in the context of an individual's life, and argued that the term "depression" should be used instead of "melancholia."[12]

The first version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) published in 1952, contained "depressive reaction" and the DSM-II, published in 1968, contained "depressive neurosis." These were defined as an excessive reaction to internal conflict or an identifiable event, and also included a depressive type of manic-depressive psychosis within the area of "Major affective disorders."[13]

The term "Major Depressive Disorder was introduced by a group of US clinicians in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms (called the "Research Diagnostic Criteria," building on the earlier Feighner Criteria).[14] The American Psychiatric Association added "major depressive disorder" to the DSM-III, published in 1980, as a split of the previous depressive neurosis in the DSM-II, which also encompassed the conditions now known as dysthymia (or Persistent Depressive Disorder or PDD) and adjustment disorder with depressed mood.[15]

To maintain consistency, the World Health Organization's International Classification of Diseases (ICD-10) used the same criteria, with only minor alterations. It used the DSM diagnostic threshold to mark a "mild depressive episode," adding higher threshold categories for moderate and severe episodes.[16] The ancient idea of "melancholia: still survives in the notion of a melancholic subtype.

Symptoms

300px\An 1892 lithograph of a woman diagnosed with melancholia

Major depression significantly affects a person's family and personal relationships, work or school life, sleeping and eating habits, and general health.[17] A person having a major depressive episode usually exhibits a low mood, which pervades all aspects of life, and an inability to experience pleasure in previously enjoyable activities. They may be preoccupied with—or ruminate over—thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness or hopelessness.[3]

Other symptoms of depression include poor concentration and memory, withdrawal from social situations and activities, reduced sex drive, irritability, and thoughts of death or suicide. Insomnia is common; in the typical pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or oversleeping, can also happen. In severe cases, depressed people may have psychotic symptoms. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant.[3]

A depressed person may report multiple physical symptoms such as fatigue, headaches, or digestive problems. Appetite often decreases, resulting in weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice agitation or lethargy. Elderly people may not present with classical depressive symptoms; they may have cognitive symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements. Depressed children may often display an irritable rather than a depressed mood; most lose interest in school and show a steep decline in academic performance.[3]

Causes

A cup analogy demonstrating the diathesis–stress model that under the same amount of stressors, person 2 is more vulnerable than person 1, because of their predisposition.[18]

Major depressive disorder is believed to be caused by a combination of genetic, environmental, and psychological factors: In other words, biological, psychological, and social factors all play a role in causing depression. Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance use disorders.[1][3]

The diathesis–stress model specifies that depression results when a preexisting vulnerability, or diathesis, is activated by stressful life events. The preexisting vulnerability can be either genetic, implying an interaction between nature and nurture, or schematic, resulting from views of the world learned in childhood.[19]

American psychiatrist Aaron Beck suggested that a triad of automatic and spontaneous negative thoughts about the self, the world or environment, and the future may lead to other depressive signs and symptoms.[20]

Adverse childhood experiences (incorporating childhood abuse, neglect and family dysfunction) markedly increase the risk of major depression.[3] Childhood trauma also correlates with severity of depression, poor responsiveness to treatment, and length of illness.

There has been a continuing discussion of whether neurological disorders and mood disorders may be linked to creativity, a discussion that goes back to Aristotelian times.[21] British literature gives many examples of reflections on depression.[22] English philosopher John Stuart Mill experienced a several-months-long period of what he called "a dull state of nerves," when one is "unsusceptible to enjoyment or pleasurable excitement; one of those moods when what is pleasure at other times, becomes insipid or indifferent." He quoted English poet Samuel Taylor Coleridge's "Dejection" as a perfect description of his case: "A grief without a pang, void, dark and drear, / A drowsy, stifled, unimpassioned grief, / Which finds no natural outlet or relief / In word, or sigh, or tear."[23] English writer Samuel Johnson used the term "the black dog" in the 1780s to describe his own depression, and it was subsequently popularized by British Prime Minister Sir Winston Churchill, who also had the disorder.[24]

Depression can also come secondary to a chronic or terminal medical condition, such as HIV/AIDS or asthma, and may be labeled "secondary depression."[25] It is unknown whether the underlying diseases induce depression through effect on quality of life, or through shared etiologies (such as degeneration of the basal ganglia in Parkinson's disease or immune dysregulation in asthma). Depression may also be iatrogenic (the result of healthcare), such as depression as a side effect of prescribed medications. Depression occurring after giving birth, postpartum depression, is thought to be the result of hormonal changes associated with pregnancy. Seasonal affective disorder is a type of depression associated with seasonal changes in sunlight where people who have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year, most often in winter.

Diagnosis

There is no laboratory test for clinical depression, and so diagnosis is based on the person's reported experiences, behavior reported by relatives or friends, and a mental status examination, although tests may be conducted to rule out physical conditions that can cause similar symptoms.[26]

Clinical assessment

Caricature of a man with depression

A diagnostic assessment may be conducted by a suitably trained general practitioner, or by a psychiatrist or psychologist, who records the person's current circumstances, biographical history, current symptoms, family history, and alcohol and drug use. The assessment also includes a mental state examination, which is an assessment of the person's current mood and thought content, in particular the presence of themes of hopelessness or pessimism, self-harm or suicide, and an absence of positive thoughts or plans.[17]

Rating scales are not used to diagnose depression, but they provide an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose, including the Hamilton Rating Scale for Depression, the Beck Depression Inventory, and the Suicide Behaviors Questionnaire-Revised.

Specialist mental health services are rare in rural areas, especially in developing countries, and thus diagnosis and management is left largely to primary-care clinicians. Since primary-care physicians have more difficulty with under-recognition and under-treatment of depression compared to psychiatrists, they often miss cases where people experience physical symptoms accompanying their depression.

A doctor generally performs a medical examination and selected investigations to rule out other causes of depressive symptoms. These can include blood tests to exclude hypothyroidism and metabolic disturbance, or a systemic infection or chronic disease.Testosterone levels may be evaluated to diagnose hypogonadism, a cause of depression in men. Adverse affective reactions to medications or alcohol misuse may be ruled out, as well. 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, which can be rule out through Cognitive testing and brain imaging.

DSM and ICD criteria

The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD). The latter system is typically used in European countries, while the former is used in the US and many other non-European nations, and the authors of both have worked towards conforming one with the other. Both DSM and ICD mark out typical (main) depressive symptoms.[16]

ICD-11

Under mood disorders, ICD-11 classifies major depressive disorder as either "single episode depressive disorder" (where there is no history of depressive episodes, or of mania)[27] or "recurrent depressive disorder" (where there is a history of prior episodes, with no history of mania).[28] These two disorders are classified as "Depressive disorders," in the category of "Mood disorders". The symptoms, which must affect work, social, or domestic activities and be present nearly every day for at least two weeks, are a depressed mood or anhedonia, accompanied by other symptoms such as "difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue."[27][28] The ICD-11 system allows further specifiers for the current depressive episode: the severity (mild, moderate, severe, unspecified); the presence of psychotic symptoms (with or without psychotic symptoms); and the degree of remission if relevant (currently in partial remission, currently in full remission).[27][28]

DSM-5

Major depressive disorder is classified as a mood disorder in DSM-5. There are two main depressive symptoms: a depressed mood, and loss of interest/pleasure in activities (anhedonia). These symptoms, as well as five out of the nine more specific symptoms listed, must frequently occur for more than two weeks (to the extent in which they impair functioning) for the diagnosis. Further qualifiers are used to classify both the episode itself and the course of the disorder. The category Unspecified Depressive Disorder is diagnosed if the depressive episode's manifestation does not meet the criteria for a major depressive episode.[3]

A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks. Episodes may be isolated or recurrent and are categorized as mild (few symptoms in excess of minimum criteria), moderate, or severe (marked impact on social or occupational functioning). An episode with psychotic features—commonly referred to as "psychotic depression"—is automatically rated as severe. If the person has had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is made instead.

Bereavement is not an exclusion criterion in DSM-5, and it is up to the clinician to distinguish between normal reactions to a loss and MDD. Excluded are a range of related diagnoses, including dysthymia, which involves a chronic but milder mood disturbance; recurrent brief depression, consisting of briefer depressive episodes; minor depressive disorder, whereby only some symptoms of major depression are present; and adjustment disorder with depressed mood, which denotes low mood resulting from a psychological response to an identifiable event or stressor.[3]

The DSM-5 recognizes six further subtypes of MDD, called "specifiers," in addition to noting the length, severity, and presence of psychotic features:[3]

  • "Melancholic depression" is characterized by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
  • "Atypical depression" is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (comfort eating), excessive sleep or sleepiness (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant long-term social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
  • "Catatonic depression" is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here, the person is mute and almost stuporous, and either remains immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur in schizophrenia or in manic episodes, or may be caused by neuroleptic malignant syndrome.
  • "Depression with anxious distress" was added into the DSM-5 as a means to emphasize the common co-occurrence between depression or mania and anxiety, as well as the risk of suicide of depressed individuals with anxiety.
  • "Depression with peri-partum onset" refers to the intense, sustained, and sometimes disabling depression experienced by women after giving birth or while a woman is pregnant. To qualify as depression with peripartum onset, onset must occur during pregnancy or within one month of delivery.
  • "Seasonal affective disorder" (SAD) is a form of depression in which depressive episodes come on in the autumn or winter, and resolve in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a two-year period or longer.

Differential diagnoses

Other disorders need to be ruled out before diagnosing major depressive disorder. They include depressions due to physical illness, medications, and substance use disorders. Depression due to physical illness is diagnosed as a mood disorder due to a general medical condition. This condition is determined based on history, laboratory findings, or physical examination. When the depression is caused by a medication, non-medical use of a psychoactive substance, or exposure to a toxin, it is then diagnosed as a specific mood disorder (previously called substance-induced mood disorder).[3]

To confirm major depressive disorder as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, adjustment disorder with depressed mood, or bipolar disorder. Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression. 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.[3]

Cultural differences

There are cultural differences in the extent to which serious depression is considered an illness requiring personal professional treatment, or an indicator of something else, such as the need to address social or moral problems, the result of biological imbalances, or a reflection of individual differences in the understanding of distress that may reinforce feelings of powerlessness, and emotional struggle.[29]

A diagnosis of illness is less common in some countries, such as China. It has been suggested that the Chinese traditionally deny or somatize emotional depression. Alternatively, it may be that Western cultures reframe and elevate some expressions of human distress to disorder status. Australian professor Gordon Parker and others have argued that the Western concept of depression medicalizes sadness or misery.[30] Similarly, Hungarian-American psychiatrist Thomas Szasz and others argue that depression is a metaphorical illness that is inappropriately regarded as an actual disease,[31] or that there is a failure to take into consideration the influence of social constructs.[32]

Management

The pathophysiology of depression is not completely understood. The most common and effective treatments are psychotherapy, medication, and electroconvulsive therapy (ECT); a combination of treatments being the most effective approach.

American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and personal preference. Options may include pharmacotherapy, psychotherapy, exercise, ECT, transcranial magnetic stimulation (TMS), or light therapy. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all people with severe depression unless ECT is planned.[33]

Talk therapies

Talk therapy, or psychotherapy can be delivered to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.

The most commonly used form of psychotherapy for depression is Cognitive Behavioral Therapy (CBT), which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. CBT and interpersonal psychotherapy (IPT) are preferred treatments for adolescent depression; in people under 18, according to the National Institute for Health and Clinical Excellence, medication should be offered only in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy.[34] Several variants of cognitive behavior therapy have been used in treating depression, the most notable being rational emotive behavior therapy[20] and mindfulness-based cognitive therapy.[35]

Psychoanalysis, founded by Sigmund Freud, emphasizes the resolution of unconscious mental conflicts, and has been used to treat patients with major depression. A more widely practiced therapy, called psychodynamic psychotherapy, is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus.[36]

Antidepressants

Antidepressants are commonly prescribed to treat major depressive disorder. The treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is often recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.[17]

The UK National Institute for Health and Care Excellence (NICE) guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk to benefit ratio is poor. The guidelines recommended that antidepressant treatment be considered for:

  • People with a history of moderate or severe depression
  • Those with mild depression that has been present for a long period
  • As a second-line treatment for mild depression that persists after other interventions
  • As a first-line treatment for moderate or severe depression

The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least six months to reduce the risk of relapse, and that selective serotonin reuptake inhibitor (SSRIs) are typically better tolerated than other antidepressants.[37] To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried.

American Psychiatric Association treatment guidelines recommended antidepressant medication as an initial treatment choice in people with mild, moderate, or severe major depression, that should be given to all people with severe depression unless ECT is planned.[33]

Electroconvulsive therapy

Electroconvulsive therapy (ECT), along with antidepressants and psychotherapy, is one of the three major treatments of depression. It has been found to reduce depression symptoms regardless of whether antidepressants are involved. ECT is a standard psychiatric treatment in which seizures are electrically induced in a person with depression to provide relief from psychiatric illnesses. ECT is used with informed consent as a last line of intervention for major depressive disorder.[38]

Lifestyle

Physical exercise has been found to be effective for major depression, and may be recommended to people who are willing, motivated, and healthy enough to participate in an exercise program as treatment. Sleep and diet may also play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.[39]

Prognosis

Major depressive episodes often resolve over time, whether or not they are treated. However, the majority of those with a first major depressive episode will have at least one more during their lifetime.

Ability to work

Depression may affect people's ability to work. The combination of usual clinical care and support with return to work (like working less hours or changing tasks) leads to fewer depressive symptoms and improved work capacity. Additional psychological interventions (such as online cognitive behavioral therapy) as well as streamlining care or adding specific providers for depression care improve ability to work.

Life expectancy and the risk of suicide

Depressed individuals have a shorter life expectancy than those without depression, in part because people who are depressed are at risk of dying of suicide. Approximately half the people who die of suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and borderline personality disorder.[36][40]

Those suffering from major depression also have a higher rate of dying from other causes. People with major depression are at risk death from cardiovascular disease, especially since they less likely to follow medical recommendations for its treatment and prevention, further increasing their risk of medical complications.

Epidemiology

Major depressive disorder affects millions of people throughout the world. Women are more affected than men, although although it is unclear why this is so.

People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60.[41] The risk of major depression is increased with neurological conditions such as stroke, Parkinson's disease, or multiple sclerosis, and during the first year after childbirth.[42]

Comorbidity

Major depression frequently co-occurs with other psychiatric problems, as well as increased rates of alcohol and drug abuse. For example, Post-traumatic stress disorder and depression often co-occur.[17] Depression often occurs in individuals with attention deficit hyperactivity disorder (ADHD), complicating the diagnosis and treatment of both.[43]

anxiety symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability, and increased suicidal behavior.[44]

Depression and pain often co-occur, although it is under-recognized, and therefore under-treated, in patients presenting with pain. Depression often coexists with physical disorders common among the elderly, such as stroke, other cardiovascular diseases, Parkinson's disease, and chronic obstructive pulmonary disease.

Social stigma

Historical figures were often reluctant to discuss or seek treatment for depression due to social stigma about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. People who may have had depression include English author Mary Shelley,[45] American-British writer Henry James,[46] and American president Abraham Lincoln.[47]

Some pioneering psychologists, such as Americans William James[48] and John B. Watson,[49] dealt with their own depression.

Social stigma of major depression continues to be widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly.[50]

Notes

  1. 1.0 1.1 1.2 1.3 1.4 Depression National Institute of Mental Health (NIMH). Retrieved October 10, 2022.
  2. C. Steven Richards and Michael W. O'Hara (eds.), The Oxford Handbook of Depression and Comorbidity (Oxford University Press, 2014, ISBN 978-0199797004).
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (American Psychiatric Publishing, Inc., 2013, ISBN 978-0890425558).
  4. Joshua Wolf Shenk, Lincoln's Great Depression The Atlantic, October 2005. Retrieved October 14, 2022.
  5. Field Maloney, The Depression Wars: Would Honest Abe Have Written the Gettysburg Address on Prozac? Slate, November 3, 2005. Retrieved October 14, 2022.
  6. Hippocrates, Aphorisms, Section 6.23.
  7. 7.0 7.1 7.2 Jennifer Radden, Is This Dame Melancholy? Equating Today's Depression and Past Melancholia Philosophy, Psychiatry, & Psychology 10(1) (2003): 37–52. Retrieved October 14, 2022.
  8. Depress Dictionary.com. Retrieved October 14, 2022.
  9. 9.0 9.1 Lewis Wolpert, Malignant Sadness: The Anatomy of Depression (Free Press, 2000, ISBN 978-0684870588).
  10. G.E. Berrios, Melancholia and depression during the 19th century: a conceptual history The British Journal of Psychiatry 153(3) (September 1988): 298–304. Retrieved October 14, 2022.
  11. Sigmund Freud, On Murder, Mourning, and Melancholia (Penguin Classic, 2005, ISBN 978-0141183794).
  12. A.J. Lewis, Melancholia: A historical review Journal of Mental Science 80(328) (January 1934): 1-42. Retrieved October 14, 2022.
  13. Committee on Nomenclature and Statistics of the American Psychiatric Association, Diagnostic and statistical manual of mental disorders: DSM-II (American Psychiatric Association, 1968), 36–37, 40.
  14. Robert L. Spitzer, The Development of Diagnostic Criteria in Psychiatry Research diagnostic criteria (RDC), 1975. Retrieved October 14, 2022.
  15. Johan Rosqvist and Michel Hersen (eds.), Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults (Wiley, 2007, ISBN 978-0471779995).
  16. 16.0 16.1 Alan M. Gruenberg, Reed D. Goldstein, and Harold Alan Pincus, "Classification of Depression: Research and Diagnostic Criteria: DSM-IV and ICD-10" in Julio Licinio and Ma-Li Wong (eds.), Biology of Depression: From Novel Insights to Therapeutic Strategies (Wiley-Blackwell, 2005, ISBN 3527307850), 1–12.
  17. 17.0 17.1 17.2 17.3 Depression National Institute of Mental Health (NIMH), 2021. Retrieved October 16, 2022.
  18. Benjamin L. Hankin and John R.Z. Abela, Development of Psychopathology: A Vulnerability-Stress Perspective (SAGE Publications, Inc, 2005, ISBN 1412904900).
  19. George M. Slavich, Deconstructing depression: A diathesis-stress perspective Association for Psychological Science (APS), September 3, 2004. Retrieved October 16, 2022.
  20. 20.0 20.1 Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery, Cognitive Therapy of Depression (The Guilford Press, 1987, ISBN 978-0898629194).
  21. Nancy C. Andreasen, The relationship between creativity and mood disorders Dialogues in Clinical Neuroscience 10(2) (2008): 251–255. Retrieved October 16, 2022.
  22. Carol F. Heffernan, The Melancholy Muse: Chaucer, Shakespeare and Early Medicine (Duquesne University Press, 1995, ISBN 978-0820702629).
  23. John Stuart Mill, Autobiography (Adamant Media Corporation, 2000, ISBN 978-1421242002).
  24. Kerrie Eyers (ed.), Tracking the Black Dog (University of New South Wales, 2006, ISBN 978-0868408125).
  25. Paula J. Clayton and C.E. Lewis, The significance of secondary depression Journal of Affective Disorders 3(1) (March 1981): 25–35. Retrieved October 16, 2022.
  26. Lauren L. Patton and Michael Glick (eds.), The ADA Practical Guide to Patients with Medical Conditions 2nd Edition (Wiley-Blackwell, 2015, ISBN 978-1118924402).
  27. 27.0 27.1 27.2 6A70 Single episode depressive disorder ICD-11. Retrieved October 17, 2022.
  28. 28.0 28.1 28.2 6A71 Recurrent depressive disorder ICD-11. Retrieved October 17, 2022.
  29. Alison Karasz, Cultural differences in conceptual models of depression Social Science & Medicine 60(7) (Aoruk 2995): 1625–1635. Retrieved October 14, 2022.
  30. Gordon Parker, Is depression overdiagnosed? Yes BMJ 335(7615) (August 2007): 328. Retrieved October 17, 2022.
  31. Warren Steibel, Is depression a disease? Debatesdebates, May 13, 1998, Retrieved October 17, 2022.
  32. Dan G. Blazer, The Age of Melancholy: "Major Depression" and its Social Origin (Routledge, 2005, ISBN 978-0415951883).
  33. 33.0 33.1 Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition American Psychiatric Association, 2010. Retrieved October 17, 2022.
  34. National Institute for Health and Clinical Excellence (NICE), How to use antidepressants in children and young people Depression in children and young people: identification and management NICE guideline, June 25, 2019. Retrieved October 17, 2022.
  35. Helen F. Coelho, Peter H. Canter, and Edzard Ernst, Mindfulness-based cognitive therapy: evaluating current evidence and informing future research Journal of Consulting and Clinical Psychology 75(6) (December 2007): 1000–1005. Retrieved October 17, 2022.
  36. 36.0 36.1 David H. Barlow, Vincent Mark Durand, and Stefan G. Hofmann, Abnormal Psychology: An Integrative Approach (8th edition) (Cengage Learning, 2017, ISBN 978-1305950443).
  37. National Collaborating Centre for Mental Health (NCCMH), Depression: The NICE Guideline on the Treatment and Management of Depression in Adults (RCPsych Publications, 2010, ISBN 978-1904671855).
  38. Ming Li, Xiaoxiao Yao, et al, Effects of Electroconvulsive Therapy on Depression and Its Potential Mechanism Frontiers in Psychology, 11(80) (2020). Retrieved October 17, 2022.
  39. Adrian L. Lopresti, Sean D. Hood, Peter D. Drummond, A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise Journal of Affective Disorders 148(1) (May 2013): 12–27. Retrieved October 17, 2022.
  40. Stephen Strakowski and Erik Nelson, Major Depressive Disorder (Oxford University Press, 2015, ISBN 978-0190206185)
  41. W.W. Eaton et al, Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up] Archives of General Psychiatry 54(11) (November 1997): 993–999. Retrieved October 17, 2022.
  42. Hugh Rickards, Depression in neurological disorders: Parkinson's disease, multiple sclerosis, and stroke Journal of Neurology, Neurosurgery, and Psychiatry 76(Suppl 1) (March 2005): i48–52. Retrieved October 17, 2022.
  43. Edward M. Hallowell and John J. Ratey, Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder (Ballantine Books, 2005, ISBN 978-0345442314).
  44. Robert M.A. Hirschfeld, The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care Primary Care Companion to the Journal of Clinical Psychiatry 3(6) (December 2001): 244–254. Retrieved October 18, 2022.
  45. Miranda Seymour, Mary Shelley (Grove Press, 2002, ISBN 978-0802139481).
  46. Leon Edel (ed.), The Letters of Henry James 1883–1895 (Belknap Press, 1980, ISBN 978-0674387829).
  47. Michael Burlingame, The Inner World of Abraham Lincoln (University of Illinois Press, 1997, ISBN 978-0252066672).
  48. William James, Letters of William James (Kessinger Publishing, LLC, 2003, ISBN 978-0766175662)
  49. David Cohen, J.B. Watson: The Founder of Behaviourism (Routledge Kegan & Paul, 1979, ISBN 978-0710000545).
  50. Gavin Andrews and Scott Henderson (eds.), Unmet Need in Psychiatry: Problems, Resources, Responses (Cambridge University Press, 2006, ISBN 978-0521027236).

References
ISBN links support NWE through referral fees

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. American Psychiatric Publishing, Inc., 2013. ISBN 978-0890425558
  • Andrews, Gavin, and Scott Henderson (eds.). Unmet Need in Psychiatry: Problems, Resources, Responses. Cambridge University Press, 2006. ISBN 978-0521027236
  • Barlow, David H., Vincent Mark Durand, and Stefan G. Hofmann. Abnormal Psychology: An Integrative Approach (8th edition). Cengage Learning, 2017. ISBN 978-1305950443
  • Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. Cognitive Therapy of Depression. The Guilford Press, 1987. ISBN 978-0898629194
  • Blazer, Dan G. The Age of Melancholy: "Major Depression" and its Social Origin. Routledge, 2005. ISBN 978-0415951883
  • Burlingame, Michael. The Inner World of Abraham Lincoln. University of Illinois Press, 1997. ISBN 978-0252066672
  • Cohen, David. J.B. Watson: The Founder of Behaviourism. Routledge Kegan & Paul, 1979. ISBN 978-0710000545
  • Committee on Nomenclature and Statistics of the American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-II. American Psychiatric Association, 1968. ASIN B0030A4JAE
  • Edel, Leon (ed.). The Letters of Henry James 1883–1895. Belknap Press, 1980. ISBN 978-0674387829
  • Eyers, Kerrie (ed.). Tracking the Black Dog. University of New South Wales, 2006. ISBN 978-0868408125
  • Freud, Sigmund. On Murder, Mourning, and Melancholia. Penguin Classic, 2005. ISBN 978-0141183794
  • Hallowell, Edward M., and John J. Ratey. Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder. Ballantine Books, 2005. ISBN 978-0345442314
  • Hankin, Benjamin L., and John R.Z. Abela. Development of Psychopathology: A Vulnerability-Stress Perspective. SAGE Publications, Inc, 2005. ISBN 1412904900
  • Heffernan, Carol F. The Melancholy Muse: Chaucer, Shakespeare and Early Medicine. Duquesne University Press, 1995. ISBN 978-0820702629
  • James, William. Letters of William James. Kessinger Publishing, LLC, 2003. ISBN 978-0766175662
  • Licinio, Julio, and Ma-Li Wong (eds.). Biology of Depression: From Novel Insights to Therapeutic Strategies. Wiley-Blackwell, 2005. ISBN 3527307850
  • Mill, John Stuart. Autobiography. Adamant Media Corporation, 2000. ISBN 978-1421242002
  • National Collaborating Centre for Mental Health (NCCMH). Depression: The NICE Guideline on the Treatment and Management of Depression in Adults. RCPsych Publications, 2010. ISBN 978-1904671855
  • Patton, Lauren L., and Michael Glick (eds.). The ADA Practical Guide to Patients with Medical Conditions 2nd Edition. Wiley-Blackwell, 2015. ISBN 978-1118924402
  • Richards, C. Steven, and Michael W. O'Hara (eds.). The Oxford Handbook of Depression and Comorbidity. Oxford University Press, 2014. ISBN 978-0199797004
  • Rosqvist, Johan, and Michel Hersen (eds.). Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults. Wiley, 2007. ISBN 978-0471779995
  • Seymour, Miranda. Mary Shelley. Grove Press, 2002. ISBN 978-0802139481
  • Wolpert, Lewis. Malignant Sadness: The Anatomy of Depression. Free Press, 2000. ISBN 978-0684870588

External links

All links retrieved October 18, 2022.

Credits

New World Encyclopedia writers and editors rewrote and completed the Wikipedia article in accordance with New World Encyclopedia standards. This article abides by terms of the Creative Commons CC-by-sa 3.0 License (CC-by-sa), which may be used and disseminated with proper attribution. Credit is due under the terms of this license that can reference both the New World Encyclopedia contributors and the selfless volunteer contributors of the Wikimedia Foundation. To cite this article click here for a list of acceptable citing formats.The history of earlier contributions by wikipedians is accessible to researchers here:

The history of this article since it was imported to New World Encyclopedia:

Note: Some restrictions may apply to use of individual images which are separately licensed.