Allegation System | Rule and Procedure | Policy Transmittalsl | Federal and State Law | Clinical Skills and Research | Table of Contents
Depression: A Clinical Information Guide
INTRODUCTION | INCIDENCE & PREVALENCE | CAUSES | SYMPTOMS | DEPRESSION IN CHILDREN AND ADOLESCENTS | INCIDENCE AND PREVALENCE | CAUSES | SYMPTOMS | DIAGNOSIS | ASSESSMENT | TREATMENT | FUTURE RESEARCH | WHERE TO GET HELP: RESOURCES
Clinical depression is a type of psychiatric disorder in which the person affected typically displays several symptoms, often including a loss of interest in normal daily activities that used to be enjoyed, as well as feelings of sadness, helplessness, and hopelessness. The depressed person may have frequent crying spells or, in the case of a child, may exhibit a greater degree of irritability than is usually present. Clinical depression differs from "feeling blue" in that the symptoms are both more severe and longer lasting. Clinical social workers, psychiatrists and psychologists use several specific criteria in diagnosing clinical depression. Increasingly, research indicates that at least in some cases of depression, there is a biological basis for the condition. In many cases, both biological factors as well as environmental factors contribute to the depression. Treatments for clinical depression vary and include psychotherapy, the use of psychotropic medications, and in the case of severe depression that does not respond to other treatments, electroconvulsive therapy. In many cases, a combination of treatments proves to be the most effective.
This clinical information guide includes information concerning the different forms of clinical depression, the criteria used in diagnosing a depressive disorder, and a description of common symptoms that may lead a person to seek treatment, as well as the different types of treatments available, current research in depression, common barriers to receiving treatment, and resources available to learn more about the illness and ways in which care providers may assist the depressed individual.
Currently, over 19 million Americans suffer from a depressive illness; as many as 2 million of these are children and adolescents. Major Depressive Disorder, the most frequently occurring form of depression, is twice as common in adolescents and adult females as in adolescent and adult males. Among prepubertal children, there is no sex difference in the incidence of major depressive disorder. Among adults, Major Depressive Disorder occurs most frequently between the ages of 25 and 44; rates are lower for men and women over the age of 65.
Among the general adult population, the lifetime risk of developing a Major Depressive Disorder is between 10 and 25% for women and between 5 and 12% for men. At a given time, between 5 and 9% of women and 2 to 3% of men meet the criteria for a Major Depressive Disorder. These rates appear to be unrelated to ethnicity, education, income level, or marital status.
A Major Depressive Disorder may begin at any age; the average age of onset is in the mid-20s, however studies indicate that the age at onset is decreasing for those born more recently. Major Depressive Episodes may be preceded by a period of anxiety and mild depressive symptoms that may last for weeks to months. The duration of a Major Depressive Episode is variable; typically, if left untreated, an episode lasts six months or longer. Some individuals then experience complete remission of symptoms, while in approximately 20 to 30% of individuals with a major depressive episode, less severe symptoms are present for months to years. In approximately 5 to 10% of cases, the full criteria for Major Depressive Episode continue to be experienced for two or more years; in this case, the depression is considered to be chronic. While some individuals may have depressive episodes separated by several years during which they are symptom-free, others may have clusters of episodes. In some cases, the frequency of episodes increases as the individual ages.
Approximately 50 to 60% of persons with a single episode can be expected to have a second episode. In persons who have had two episodes, the likelihood of a third is approximately 70%; for those who have had three, this percentage climbs to 90%. There is a greater chance of experiencing another episode in persons who undergo only partial remission, as compared to those who enter a stage of complete remission. The severity of the first episode is predictive of persistence of symptoms over time.
Depression is often found in conjunction with other disorders, both psychological and physical. Anxiety disorders, including panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, social phobia, or generalized anxiety disorder are frequently co-exist with depression. Depression also can increase the risk for physical illness, disabilities, and premature death. In addition, the presence of depression may hinder a person's ability to seek and maintain appropriate treatment for medical conditions. Recent research has suggested that persons with a history of major depression have a four times greater risk of having a heart attack, compared to persons without depression. Even in cases of mild depression, those who have a history of two or more weeks of mild depression have been found to be twice as likely to have a heart attack, compared to persons without such history. Research is currently aimed at determining whether treatment for depression reduces the increased of heart attack in depressed populations.
Major depression has many causes. Researchers believe that genes, biology, psychology, and life stress all play a role. Biochemical research has indicated that irregularities in specific brain chemicals called neurotransmitters may be important. Personality characteristics such as chronic pessimism or low self-esteem may contribute to the development of depression. Stressful life events such as death, divorce, or financial difficulties can contribute to depression. A familial pattern appears to be present in Major Depressive Disorder: The disorder is 1.5 to 3 times more common among first-degree biological relatives of persons with the disorder than among the general population. Other risk factors for depression include cigarette smoking, general medical illness, and drug or alcohol use.
The essential feature of a Major Depressive Disorder is a period of at least two weeks during which the person exhibits either depressed mood or loss of interest or pleasure in nearly all activities. In contrast to adults, children and adolescents may exhibit irritability rather than sadness. Persons experiencing a major depressive episode often describe themselves as feeling sad, hopeless, discouraged, anxious, or as having no feelings (feeling "numb"). In some, depression is manifested as somatic complaints (for example, bodily aches and pains, gastrointestinal disturbances). Often there is increased irritability, persistent anger, a tendency to respond to events with angry outbursts, persistent blaming of others, or an exaggeration of frustration over minor matters.
People with depression often lose interest in hobbies, withdraw from others, avoid social engagements, or, in the case of a child, lose interest or avoid activities that used to bring pleasure (sports, for example). Appetite is usually affected by a major depressive episode; typically, appetite is reduced, though in some cases it may be increased, often with specific food cravings (sweets or carbohydrates, for example). These changes in appetite may cause significant weight loss or gain. In children, they may fail to make expected weight gains.
Sleep is often disturbed during a major depressive episode. The most common sleep disturbance is insomnia; persons may have difficulty falling asleep, may awaken in the middle of the night and have difficulty returning to sleep, or may awaken too early and be unable to return to sleep. In some cases, the depressed person may exhibit hypersomnia, or oversleeping. It is not uncommon for child welfare workers to be confronted with the phenomena of parental over-sleeping. Parental depression, often combined with substance abuse, results in children having to dress, make their own breakfast and lunches, and wash-up in the mornings because their parents are over sleeping.
Persons experiencing a major depressive episode may also display psychomotor agitation; they may have difficulty sitting still, they may pace or rub their hands together repeatedly. In other cases, the person may display psychomotor retardation; speech, thinking, and body movements may be slowed, or the volume of speech may be decreased. Often, people experiencing a major depressive episode report feeling tired, fatigued, or lacking energy; even small tasks seem to require more energy than is available to the person. Common tasks such as bathing and dressing may require longer periods of time to accomplish and result in a feeling of exhaustion.
Many persons who are experiencing a major depressive episode report having difficulty thinking, concentrating, or making decisions. Distractibility may be a problem, as may memory impairments. In children, this may be manifested as a precipitous drop in grades, which may be a reflection of poor concentration. In parents, decreased memory caused by depression, results in missed appointments, failure to follow through with routine household activities (laundry, cleaning), and reduced ability to make decisions regarding their children. In elderly people, memory difficulties are sometimes mistaken for early signs of dementia.
Persons undergoing a major depressive episode often experience feelings of unrealistic guilt or worthlessness; trivial events are misinterpreted as evidence of personal defects, and responsibility is taken for untoward events. There may also be thoughts of death, suicidal ideation, or actual suicide attempts. The depressed person may believe that others would be better off if the person were dead. Often, motivation for suicide may include a desire to give up when the obstacles are perceived as insurmountable, or a desire to end an extremely painful emotional state that is seen as unending.
Persons experiencing a major depressive episode often present with tearfulness, irritability, obsessive rumination, anxiety, brooding, excessive worry over physical health, and complaints of headaches, abdominal distress, or other body pains. In some cases, persons may experience panic attacks. Sexual dysfunction may be present, and relationships may be disturbed. In children, separation anxiety may be present, or academic problems such as truancy or school failure may occur.
The core symptoms of a major depressive episode in children and adolescents are the same as for an adult, although certain characteristics may predominate at certain ages. In children, somatic complaints such as stomachaches or headaches are common. Likewise, in children, irritability and social withdrawal are common symptoms of a major depressive episode. In prepubertal children, Major Depressive Episodes occur more frequently in conjunction with other disorders such as disruptive behavior disorders, attention deficit disorders, anxiety disorders, eating disorders, and substance-related disorders. In adolescents, there is a greater tendency to display psychomotor retardation, hypersomnia, and delusions.
The most serious consequence of a Major Depressive Episode can be attempted or completed suicide. While many studies indicate that it is not possible to predict accurately whether or when a particular depressed person will attempt suicide, certain individuals are considered at higher risk: those who exhibit depressive symptoms with psychotic features, those who have made previous attempts, those who are abusing alcohol or other substances, and those who have a family history of completed suicides. Up to 15% of persons with severe Major Depressive Disorder die by suicide, and among those greater than 55-years-old, there is a fourfold increase in death rates in persons with Major Depressive Disorder.
Depression in children and adolescents has increased dramatically in the last fifty years, while the average age of onset has fallen. According to several studies, up to 2.5% of children and up to 8.3% of adolescents in the U.S. suffer from depression (Birmaher, Ryan, Williamson, et al, 1996). According to a study by the National Institutes of Health, the prevalence of any type of depression is more than 6% in a 6-month period, with 4.9% having major depression (Shaffer, Fisher, Dulkan, et al, 1996). In childhood, the number of boys and girls diagnosed is almost equal; by adolescence, twice as many girls as boys are diagnosed. While the rate of recovery from a single episode of major depression is high in children and adolescents, over half of depressed adolescents have a recurrence within seven years. Indeed, early-onset depression often persists, recurs, and continues into adulthood, and may predict more severe illness in adult life (Weissman, Wolk, Goldstein, et al, 1999). Youth with dysthymic disorder are also at risk for developing major depression.
As in adult depression, the causes of childhood and adolescent depression are varied, and may include both heredity and environmental issues. One theory holds that children inherit a predisposition to depression and anxiety, but that environmental triggers are necessary in order to elicit the initial episode of Major Depression. Environmental influences include inconsistent parenting, stressful experiences, and a negative way of viewing the world. In situations of abuse and neglect, the separation and placement of children, while necessary in certain instances to ensure their safety, will invariable result in symptoms of depression. This `excess burden' of depressive symptomatology that the child welfare system causes the very children it is helping, has been a vexing problem. Childhood depression is also associated with a family history of mood disorders and other psychiatric conditions. The risk of developing depression is higher if a relative has had childhood or recurrent depression. When asked about their childhood experiences, depressed adults are more likely to report neglect, abuse, rejection, and parental conflict (Watkins, 2000).
Depressed children often have parents who are depressed or show other symptoms of stress. It is not clear, however, whether poor parenting leads to the child's depression, or whether the stress of coping with a depressed child leads to parental rejection and poor parenting. Some suggest that irritability and withdrawal in parents leads to lowered self-esteem in the child, and that this predisposes the child to depression. Others suggest that children may inherit a genetic vulnerability which predisposes them to depression when they are exposed to family stress (Watkins, 2000).
While the symptoms of depression in children and adolescents are similar to those of adult depression, children often do not have the vocabulary to describe their feelings and therefore express these feelings through their behavior. Young children with depression are more likely to display phobias, separation anxiety disorder, somatic complaints, and behavior problems. If the depression has psychotic features, children are more likely to report having hallucinations. Older adolescents with psychotic depression, on the other hand, are more likely to have delusions, as delusions require more advanced cognitive functioning than hallucinations.
According to Watkins (2000), a depressed child or adolescent may display the following symptoms:
In preschoolers or children in early elementary school, the child might appear less bouncy, spontaneous, serious, or voice vague complaints of being sick. A depressed child may say negative things about him or herself and may demonstrate self-destructive behavior.
In older elementary school children and adolescents, grades may fall, the student may engage in disruptive behavior, and may have problems with friendships. Aggressive behavior is also sometimes seen, as is irritability and suicidal talk. The student may appear to hate himself or herself as well as everyone else.
In addition to the symptoms of Major Depressive Disorder that are common to adults as well as to children and adolescents, there are other signs that may be associated with childhood and adolescent depression. These include:
Many children who have depression also have one or more other major psychiatric diagnoses, including Anxiety Disorder, Substance Abuse, and ADHD. ADHD is sometimes present before the initial episode of depression; substance abuse often begins after the initial episode. Compared to children with only depression, children who have depression coupled with ADHD or Conduct Disorder are more likely to engage in criminal activities as adults and are more likely to make suicide attempts. Childhood depression is also associated with school and interpersonal problems, with an increased incidence of suicidal behavior, violent thoughts, use of alcohol, early pregnancy, tobacco use, and drug abuse.
Since 1950, the suicide rate among adolescents has risen four fold (Watkins, 2000). Childhood and adolescent depression is associated with an increased risk of suicidal behavior, which may rise, especially in adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse ((Weissman, et al, 1999; Shaffer, Gould, Fisher, et al, 1996; Shaffer, Craft, 1999). In 1997, suicide was the third leading cause of death among 10 to 24-year-olds (Hoyert, Kochanek, Murphy, 1999); it is the fourth among 10 to 14-year-olds (NIMH, 2000). Among adolescents with a major depressive disorder, up to 7% may commit suicide during their young adult years (Weissman, et al, 1999). Particular vigilance should be exercised with children who have a relative who committed suicide or who are exposed to family violence.
There are three primary forms of depression for adults and children as defined by the Diagnostic and Statistical Manual-IV: Major Depressive Disorder, Dysthymia, and Depression Not Otherwise Specified.
Major Depressive Disorder
The essential feature of Major Depressive Disorder is the presence of one or more Major Depressive Episodes., without a history of Manic, Mixed, or Hypomanic Episodes. In order to be diagnosed as a major depressive episode, the following criteria must be met:
1. Five or more of the following symptoms must have been present during a consecutive 2-week period, and these must represent a change from previous functioning; at least one of the symptoms must be either a depressed mood or a loss of interest or pleasure:
a. depressed mood most of the day, nearly every day, as indicated by either subjective report (for example, the person feels sad or empty) or observation made by others (for example, the person is tearful). It should be noted that in children and adolescents, depression could present as an irritable mood
b. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (again, either by subjective report or by observation by others) c. significant weight loss when not dieting or weight gain (for example, a change of more than 5% of body weight in a month), or a decrease or increase in appetite nearly every day. In children, this may be manifested as failure to make expected weight gains
c. insomnia or hypersomnia nearly every day
d. psychomotor agitation or retardation nearly every day (which is observable by others, as opposed to subjective feelings of restlessness or being slowed down)
e. fatigue or loss of energy nearly every day
f. feelings of worthlessness or excessive or inappropriate guilt (which may not be grounded in reality) nearly every day (not merely self-reproach or guilt about being sick)
g. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
h. recurrent thoughts of death (not just a fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
2. The symptoms do not meet the criteria for a Mixed Episode (discussed below).
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The symptoms are not due to the direct physiological effects of a substance (drug abuse, medication) or a general medical condition (for example, hypothyroidism).
5. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
6. In addition to these criteria, the depressive episodes must not be better accounted for by Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
A Major Depressive Disorder may be characterized by a single episode, which refers only to first episodes, or recurrent. As it is sometimes difficult to determine between a single episode that has symptoms that vary in intensity during the course of the episode and two separate episodes, an episode is considered to have ended when the full criteria for Major Depressive Episode have not been met for at least two consecutive months. During those two months, the depressed person may experience either complete remission of symptoms or experience depressive symptoms that do not meet the full criteria for a major depressive episode; in the latter case, the person is considered to be in partial remission.
Major Depressive Episodes vary in intensity; these are categorized as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. They may be accompanied by other features, and thus categorized as Chronic, With Catatonic Features, With Melancholic Features, With Atypical Features, or With Postpartum Onset.
Dysthymic Disorder
Dysthymic Disorder is a type of depressive disorder with symptoms that are less severe than those of a Major Depressive Disorder. According to the Diagnostic and Statistical Manual-IV, the essential feature of Dysthymic Disorder is a chronically depressed mood that occurs for most of the day, more days than not, for at least two years. This is accompanied by additional depressive symptoms that do not meet the criteria for a Major Depressive Episode. In children, irritability rather than depressed mood may be present, and the required minimum duration is only one year.
Dysthymic Disorder can begin in childhood, adolescence, or early adulthood. Symptoms often are not noticed immediately, and the disorder frequently follows a chronic course. Individuals with Dysthymic Disorder who seek treatment typically have a Major Depressive Disorder superimposed on the Dysthymic Disorder. If Dysthymic Disorder precedes the onset of a Major Depressive Disorder, there is less likelihood that the individual will experience full recovery between Major Depressive Episodes, and there is a greater chance of having more frequent subsequent episodes.
The lifetime prevalence of Dysthymic Disorder is approximately 6%; at any given time, approximately 3% of the population has been diagnosed with this disorder. The disorder is two to three times more likely to occur in women than in men, and is more common among first-degree biological relatives of people with Major Depressive Disorder than among the general population. Dysthymic Disorder occurs equally in boys and girls.
Symptoms of Dysthymic Disorder
It should be noted that it is often difficult to distinguish between a Major Depressive Disorder and Dysthymic Disorder. Typically, in a Major Depressive Disorder, the individual has one or more discrete Major Depressive Episodes, whereas the person with Dysthymic Disorder displays chronic, less severe depressive symptoms that have been present for many years. In persons with Dysthymic Disorder, it is often difficult to distinguish the mood disturbance from the person's "usual" functioning. Dysthymic Disorder must also be distinguished from a mood disorder that is caused by a general medical condition or a substance-induced mood disorder.
Persons with Dysthymic Disorder may view themselves as uninteresting or incapable. These symptoms may become such a part of the individual's daily experience that they are not reported, but rather attributed to "how the person is" or how they "have always been". The onset of Dysthymic Disorder may be early, before the age of 21 years, or late (age 21 or older). Those individuals who develop Dysthymic Disorder before age 21 are more likely to develop subsequent Major Depressive Episodes, and 10% of individuals with Dysthymic Disorder develop Major Depressive Disorder within one year of the onset of Dysthymic Disorder.
Several studies have found that the most common symptoms of Dysthymic Disorder are feelings of inadequacy, generalized loss of interest or pleasure, social withdrawal, feelings of guilt or brooding about the past, subjective feelings of irritability or excessive anger, and decreased activity, effectiveness, or productivity. Symptoms such as sleep, appetite, weight change, and psychomotor symptoms appear to be less common in Dysthymic Disorder than in Major Depressive Disorder. In adults, other disorders such as substance abuse or chronic psychosocial stressors may be present along with the symptoms of Dysthymic Disorder. In children, Attention Deficit Hyperactivity Disorder, Conduct Disorder, Anxiety Disorders, Learning Disorders, and Mental Retardation may also be present.
Often, children with this disorder display poor school performance and difficulty with social interactions. Children and adolescents usually appear irritable and cranky as well as depressed, and tend to have low self-esteem, poor social skills, and a pessimistic attitude.
Diagnosis of Dysthymic Disorder
The DSM-IV diagnostic criteria for Dysthymic Disorder are:
1. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years. In children and adolescents, mood can be irritable and duration must be at least one year.
2. Presence, while depressed, of two or more of the following:
a) poor appetite or overeating
b) insomnia or hypersomnia
c) low energy or fatigue
d) low self-esteem
e) poor concentration or difficulty making decisions
f) feelings of hopelessness
3. During the 2-year period (or one year for children and adolescents) of the disturbance, the person has never been without the symptoms in the first two criteria for more than two months at a time.
4. No Major Depressive Episode has been present during the first two years of the disturbance (one year for children and adolescents). There may have been a previous Major Depressive Episode, but there must have a full remission before developing Dysthymic Disorder. After the initial two years (one, for children and adolescents), episodes of a Major Depressive Disorder may be superimposed.
5. There has never been a Manic Episode, a Mixed Episode (manic and major depressive episodes), or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
6. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
7. The symptoms are not due to the direct physiological effects of a substance (for example, drug abuse or medication) or a general medical condition (for example, hypothyroidism).
8. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Depression Not Otherwise Specified
According to the Diagnostic and Statistical Manual-IV, the third type of depressive disorder includes disorders with depressive features that do not meet the criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder With Depressed Mood, or Adjustment Disorder With Mixed Anxiety and Depressed Mood.
Examples of Depressive Disorder Not Otherwise Specified include the following:
1. Premenstrual dysphoric disorder: in most menstrual cycles during the past year, symptoms such as significantly depressed mood, marked anxiety, marked affective lability, and decreased interest in activities occurred regularly during the last week of the luteal phase and remitted within a few days of the onset of menses. The symptoms are severe enough to significantly interfere with normal activities, and are entirely absent for at least one week after menses have occurred.
2. Minor depressive disorder: episodes of at least two weeks of depressive symptoms but with fewer than the five items required for a diagnosis of Major Depressive Disorder.
3. Recurrent brief depressive disorder: depressive episodes that last from two days to two weeks, that occur at least once a month for 12 months and are not associated with the menstrual cycle.
4. Post-psychotic depressive disorder of Schizophrenia: a Major Depressive Episode that occurs during the residual phase of Schizophrenia.
5. A Major Depressive Episode superimposed on Delusional Disorder, Psychotic Disorder Not Otherwise Specified, or the active phase of Schizophrenia.
6. Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
The assessment of depression should always involve a clinical interview and may involve other methods, such as standardized assessment tools or the use of structured clinical interviews. The clinician interviews the client, gathering information about the client's individual and family psychiatric and medical history and the client's social, educational, and vocational functioning.
Clinical Interview with Client
The clinical interview is designed to allow the clinician to observe the client and elicit information from the client relative to their mood, affect, cognitions (thought processes, patterns of thinking), behaviors. During the interview the clinician will attempt to engage the client in a discussion of their own view of why they are at the assessment, what, if any, issues they perceive to be important to them.
The use of structured interview techniques is often time consuming and difficult to use in clinical settings. There are two main structured interviews measures currently in use:
These structured interviews rate the severity of depressive symptoms based on the number of symptoms present and the degree of impairment.
Self-Report Assessment Measures
Self-report measures are a common means of obtaining information about depression symptoms. These measures are easy to administer and take only 10 to 30 minutes to complete. The most common self-report measures of depression are:
With any self-report instrument, there is a chance for exaggeration, denial, or minimization of symptoms by the client. Whenever possible, obtaining collateral information to support the self-report is critical.
Adult Depression
There are various types of approaches to treating depression; the optimum treatment depends on the type of depression the individual is experiencing. In the case of Major Depressive Disorder, treatments include psychotherapy, medication, and electroconvulsive therapy (ECT). The choice of treatment depends on the type and severity of symptoms, the preference of the patient, and the history of treatment responses during prior depressive episodes. In cases of severe Major Depressive Disorder, it is generally necessary to use either medication or ECT. Specific psychotherapies can be used in conjunction with medication. The response rate for people with Major Depressive Disorder treated by medication is approximately 70%; for ECT, the response rate is approximately 80%.
In the case of Dysthymic Disorder, psychotherapy alone is typically utilized. Recently, however, it has been found that 50 to 60% of persons with Dysthymic Disorder respond well to most types of antidepressant medications (Center for Evidence-Based Mental Health journal, 1998).
Psychotherapy
Several types of psychotherapy are available to treat depression. These include:
Medication
Within the brain, chemicals called neurotransmitters are responsible for conveying signals between nerve cells. The information needed to maintain mood is conveyed in part by these chemical signals. Antidepressant medications appear to work by increasing the availability of certain neurotransmitters, known as monoamines, in the brain. The neurotransmitters that are most commonly affected by antidepressant medications are serotonin and norepinepherine.
Several classes of antidepressant medications are utilized in the treatment of depression. These include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and other specific medications which do not fall into a general class.
Antidepressant medications typically take several weeks to be clinically effective, though they begin to alter brain chemistry with the first dose. Current research indicates that antidepressant effects result from slow-onset adaptive changes within the neurons. It also appears that activation of chemical messenger pathways within neurons, and changes in the way that genes in neurons are expressed, are the critical events underlying long-term adaptations in neuronal function that are relevant to antidepressant drug action. Still under investigation are the mechanisms that mediate, within cells, the long-term changes in neuronal function produced by antidepressants, as well as how these mechanisms are altered by illness (NIMH, 2000). Other areas of current research interest include discovering how and where in the brain antidepressants work, how specific antidepressants produce side effects, and the differential effectiveness of various antidepressants in persons with particular subtypes of depression (NIMH, 2000).
For some individuals, a single antidepressant medication is insufficient to bring about remission. In these cases, several options exist: another antidepressant may be tried, or the current antidepressant may be supplemented with other medications, including lithium, a tricyclic antidepressant, carbamazepine (Tegretol) or with d-amphetamine (Dexedrine) or methylphenidate (Ritalin). In the case of seasonal affective disorder, phototherapy may be added; in the case of psychotic major depression, an antipsychotic may be added. Unfortunately, at this time there is little research evidence available to guide practitioners in prescribing appropriate combination treatment (NIMH, 2000).
Electroconvulsive Therapy (ECT)
ECT typically is often used when other kinds of treatment have failed. ECT can be extremely effective for patients with severe depression and when rapid lifting of depression is considered necessary to prevent suicide. ECT has been found to have the highest response rate of any antidepressant treatment (American Psychiatric Association Practice Guidelines, 1990).
ECT is administered in a medical setting and involves the administration of a short duration anesthetic, followed by medications to relax the muscles. Electrodes are then placed on the patient's scalp and an electric current is passed through them, producing a seizure which lasts 30 to 45 seconds. Because muscle relaxants are used, there is generally little movement or chance of injury. The most common side effects of ECT are headache and transient memory disturbances; memory problems generally disappear over a few weeks to a few months. The total number of treatments given is usually between eight and twelve, with two to three treatments per week. Often, antidepressant medication or periodic "maintenance ECT" is recommended following the conclusion of treatments.
Other Treatment Modalities
Efficacy of Treatment
Approximately 80% of people with depression respond positively to treatment, while a significant number remain treatment refractory. Most scientific evidence indicates that psychological interventions, in particular cognitive-behavioral therapies, are generally as effective or more effective than medications in the treatment of depression, including severe depression (Antonuccio, 1995). Some studies have found medication alone to be substantially worse than psychotherapy alone or combined treatment (Wexler and Cicchetti, 1992, in Antonuccio, 1995); other studies, though, have found psychotherapy alone to rarely be sufficient in treating moderate to severe depression. Dropout rates tend to be higher among persons treated with medication alone, as compared to those treated with either psychotherapy alone or a combination of medication and psychotherapy (Antonuccio, 1995).
A combination of psychotherapy and medication is often prescribed for the treatment of depression. However, the relationship between the severity of a major depressive episode and the choice of treatment is highly controversial. Some studies have found that medication combined with psychotherapy was more effective than psychotherapy alone in treating more severe depression, but that the interventions were equally effective in treating less severe depression (Thase et al, 1997). Others have found that cognitive and behavioral treatments of severe depression were not significantly more effective than the use of medication alone (Hollon et al, 1992). A study by Schulberg, et al (1998) focused on the relationship between initial level of depressive severity and functional ability, treatment with nortriptyline (a tricyclic antidepressant) or interpersonal psychotherapy, and clinical course. Results indicated that among more severely depressed persons, the type of treatment used was unrelated to the clinical course. However, among less severely depressed persons, those who were prescribed the medication improved significantly more rapidly during the first three months of treatment than those who were provided psychotherapy alone. These results, however, contradict those of other studies that found that the effectiveness of psychotherapy is reduced when it is used to treat more severe depression (Thase, et al, 1997). These results also contradict the prevailing consensus that treatment type is not related to clinical course among those with milder depression.
Efficacy of treatment types continues to be studied. Shulberg, et al, suggest that because psychotherapy and medication were not found to produce significantly different outcomes, and because the preference of the individual should be considered when choosing a treatment, psychotherapy should be recommended for persons with severe major depression when the person prefers it, when the person refuses or cannot tolerate medications, when well-trained psychotherapists are available, and when the cost of psychotherapy is not problematic for the individual.
Treatment of Depression in Childhood and Adolescents
Research on the treatment of depression in children and adolescents has lagged behind that in adults (NIMH, 2000). Several factors contribute to the difficulty in diagnosing and treating childhood and adolescent depression; early symptoms may be difficult to detect or may be attributed to other causes, and because much more needs to be learned about brain development during the early years of life, it is premature to expect treatments for youth to be as successful as they are in adults. However, given the statistics on child and adolescent suicide, early diagnosis and treatment of depression is imperative.
Treatment for depression in children and adolescents often includes short-term psychotherapy, medication, or a combination of the two, as well as interventions targeting the home and/or school environment.
Psychotherapy
A variety of psychotherapeutic techniques are used in treating depression in children and adolescents. Recent research has indicated that certain types of short-term psychotherapy, in particular, cognitive-behavioral therapy, are effective in relieving depression. A 1997 NIMH study found that cognitive-behavioral therapy led to remission in nearly 65% of cases, higher than either supportive therapy or family therapy, and that cognitive behavioral therapy also resulted in more rapid treatment response (Brent, Holder, Kolko, et al, 1997).
Interpersonal therapy is also used in treating childhood and adolescent depression. While this technique has not been well investigated with youthful populations, one study found that it led to greater improvement than clinical contact alone (Mufson, Weissman, Moreau, et al, 1999). Many agree that family therapy can also help speed recovery, and that continuing psychotherapy for several months after remission may help children and families cope with the illness, address environmental stressors, and understand the factors that could contribute to relapse.
Medication
Until recently, only limited data existed on the safety and efficacy of antidepressant medications in children and adolescents (NIMH, 2000. Recent studies, however, support the use of several antidepressants. Specifically, the selective serotonin reuptake inhibitors (SSRIs) have been demonstrated to be safe and effective for the short-term treatment of severe and persistent depression in youths, though more research is needed using large clinical populations. Of the SSRIs, fluoxetine (Prozac) and paroxetine (Paxil) have been found to be effective. Tricyclic antidepressants have not been found to be effective for treating childhood and adolescent depression.
According to some (Birmaher, Brent, Benson, 1998, cited in NIMH, 2000), the choice of medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy, those who are unable to engage in psychotherapy, children and adolescents with psychosis, and those with chronic or recurrent episodes. Following remission, medication and/or psychotherapy for several months is often recommended in order to lower the risk of recurrence. Medications should be discontinued gradually over six weeks or longer (Birmaher, et al, 1998). Other factors to consider after a medication regimen is terminated are social skills groups through a school or other agency, youth groups, maintaining a balanced diet and regular sleep schedule and, if there is a seasonal component to the depression, the use of phototherapy.
Barriers to Receiving Treatment
Although over 19 million Americans suffer from a depressive illness, two thirds of these never receive any treatment. Numerous barriers to receiving treatment exist. Often, symptoms are not recognized by families or physicians as indicators of depression. This is especially true in children and adolescents, where symptoms are often seen as normal mood swings associated with a particular developmental stage. Also, health care professionals may be reticent to "label" a young person with a diagnosis of a mental disorder.
Unfortunately, considerable stigma persists with regard to mental illnesses in general. Symptoms of depression may be attributed to personal weakness, and the person suffering may be chastised to pull himself or herself "up by the bootstraps." Shame and the fear of being labeled with a mental illness prevent many people from seeking help. Often, people do not accurately report symptoms to their health care provider, leading to misdiagnosis and incorrect treatment.
People may be reluctant to seek help because they are concerned about the cost of treatment. Many are uninsured, or their insurance plans may not cover, or pay a limited amount toward the treatment of psychiatric disorders. Others do not know where to look for help.
During the course of a depressive episode, symptoms may be disabling enough to prevent a person from reaching out for help. Social withdrawal is common in depression, and may lead to a lack of contact with those who might recognize the symptoms and help the person receive appropriate treatment. Often, energy levels and motivation are so low that the person is unable to take the necessary steps to receive help. The hopelessness and helplessness that accompany depression may lead people to believe that they are "beyond hope," or that "nothing will work, anyway."
Even when people do seek treatment, barriers exist to their achieving remission of symptoms. In the case of psychopharmacologic treatment, side effects of some medications may dissuade a person from continuing therapy. Compliance with medication regimens may also pose a problem. In addition, once symptoms begin to be relieved, people sometimes stop taking the medication, leading to relapse. At times, appropriate follow-up such as maintenance medication or psychotherapy is not provided or utilized, leading to recurrence.
Many myths about depressive disorders continue to prevent people from receiving the help they need. In addition to those described above, the National Institute of Mental Health provides the following list of myths that are particularly problematic among youth:
Myth: It's normal for teenagers to be moody; teens don't suffer from real depression.
Fact: Depression is more than just being moody, and can affect people at any age, including teenagers.
Myth: Telling an adult that a friend might be depressed is betraying a trust. If someone wants help, he or she will get it.
Fact: Depression, which saps energy and self-esteem, interferes with a person's ability or desire to seek help. It is an act of true friendship to share your concerns with an adult who can help.
Myth: Talking about depression only makes it worse.
Fact: Talking through feelings with a good friend is often a helpful first step. Friendship, concern, and support can provide the encouragement to talk to a parent or other trusted adult about getting evaluated for depression.
In addition to the research on depression already described, several promising areas are currently being investigated. These include:
Genetics Research
Research suggests that genes may play an important role in vulnerability to depression, as well as other types of mental illness. Rather than a single defective gene being responsible for each type of mental illness, research now points to the contribution of multiple gene variants acting together with as yet unknown environmental risk factors and/or developmental events to produce psychiatric disorders (NIMH, 2000). The identification of these genes, however, has been an extremely challenging task. With the recent completion of the human genome project, researchers are making enormous progress in the understanding of gene variants and the development of mental disorders. The National Institute of Mental Health is currently soliciting researchers to contribute to the development of a large-scale database of genetic information that will facilitate efforts to identify susceptibility genes for depression, as well as other mental illnesses (NIMH, 2000).
The Role of Stress in Depression
It is well known that psychosocial and environmental stress are risk factors for the development of depression, and that these stressors can trigger depression in vulnerable individuals. Environmental stressors, by interacting with gene variants, which increase vulnerability to depression, increase the risk of developing a depressive disorder. In addition to studying gene variants, research is currently aimed at identifying the environmental risk factors that contribute to depression. In addition, research in early brain development is identifying the role of stressors such as social isolation, chronic environmental stress, or early-life deprivation in the development of permanent changes in brain function that increase the individual's susceptibility to depressive symptoms.
Brain Research
Through the use of functional magnetic resonance imaging, scientists are able to safely view brain structure and function in living people. This allows for the investigation of the effects of various treatments on the brain as well as understanding how these treatments affect clinical outcomes. Brain imaging may also enable researchers to identify microscopic abnormalities in the structure and functioning of the brain that are responsible for mental disorders. Eventually, it may be possible to use brain imaging as a tool for early diagnosis of depression and other mental disorders, thereby advancing the development and evaluation of new treatments (NIMH, 2000).
Hormonal Research
Research has found that the hormonal system that regulates the body's response to stress (the hypothalamic-pituitary-adrenal axis) is overactive in many individuals who suffer from depression. Current research is aimed at determining whether this over-activation actually contributes to the development of depression. Additional research is underway that investigates the role of chronic over-activation of the pituitary and adrenal glands in the development of depression. When faced with physical or psychological threats, the hypothalamus increases production of corticotrophin releasing factor (CRF). Elevated levels and effects of CRF lead to increased pituitary and adrenal hormone secretion in order to prepare the body for defensive action. It is thought that chronic physical or psychological stress leading to this over-activation of the hormonal system may predispose an individual to developing depression. CRF levels have been found to be elevated in depressed persons, and are reduced by the administration of antidepressants.
The role of female sex hormones, estrogen and progesterone, in the depression that accompanies premenstrual syndrome is also a current topic of research. Studies have demonstrated that these hormones do not cause PMS, but rather they trigger PMS symptoms in women who have a preexisting vulnerability to the disorder (NIMH, 2000). Investigations are currently underway to determine what causes susceptibility to PMS. In addition to PMS, research is focused on the mechanisms that contribute to postpartum depression.
Numerous resources to diagnose and treat depression exist. In seeking help, persons may be directed to physicians, mental health specialists, community mental health agencies, the psychiatric department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, private clinics, self-help groups, pastoral care providers, school counselors, or the local Mental Health Association.
The National Institute of Mental Health provides information on the treatment of children with mental disorders which may be useful to parents. This includes questions on the types of mental illnesses that affect children, risk factors, detecting symptoms, where to obtain help, the diagnostic processes used for children, and the use of psychotropic medications. It is available on the Internet at http://www.nimh.gov/publicat/childqu.cfm. Additional information can be obtain by contacting the agency at:
National Institute of Mental Health
Office of Communications and Public Liaison
Information Resources and Inquiries Branch
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
(301) 443-4513
nimhinfo@nih. gov.
Current information about depression can also be obtained from:
American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue, N.W.
Washington, DC 20016
(202) 96607300
American Psychiatric Association
1400 K Street, N.W.
Washington, DC 20005
(202) 682-6000
American Psychological Association
750 First Street, N.E.
Washington, DC 20002
(202) 336-5500
National Foundation for Depressive Illness, Inc.
P.O. Box 2257
New York, NY 10116
(212) 268-4260; (800) 239-1265
National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
(800) 950-NAMI (6264)
National Depressive and Manic-Depressive Association
730 N. Franklin Street, Suite 501
Chicago, IL 60601
60610-3526 (800) 826-3632
National Mental Health Association
1021 Prince Street Alexandria, VA 22314
(800) 969-NMHA (-6642)
1 Portions of this Clinical Information Guide are adapted from Depression, a patient information guide published by the National Institute of Mental Health, and Major Depressive Disorder: A Patient and Family Guide, which is published by the American Psychiatric Association.
INTRODUCTION | INCIDENCE & PREVALENCE | CAUSES | SYMPTOMS | DEPRESSION IN CHILDREN AND ADOLESCENTS | INCIDENCE AND PREVALENCE | CAUSES | SYMPTOMS | DIAGNOSIS | ASSESSMENT | TREATMENT | FUTURE RESEARCH | WHERE TO GET HELP: RESOURCES