Depression affects millions around the world. Former Lt. Governors Weston and Alexander lost close family members to depression. Michael Wilson lost a son. Former Premier Roberts took his own life. Depression is an illness where the patient often suffers in silence to avoid the stigma and fear of rejection. Dr. Alastair J. Cunnigham, author of The Healing Journey and several other books and articles invites us to participate in a healing journey where self-help plays an important role in the context of cancer treatments where many patients suffer not only physical pain associated with cancer but also from depression. What is depression?

Signs and symptoms

Clinical depression can present with a variety of symptoms, however almost all patients display a marked change in mood, a deep feeling of sadness, and a noticeable loss of interest or pleasure in favorite activities. Other symptoms include:

• Persistent sad, anxious or "empty" mood
• Loss of appetite and/or weight loss or conversely overeating and weight gain
• Insomnia, early-morning awakening, or oversleeping
• Restlessness or irritability
• Feelings of worthlessness, inappropriate guilt, helplessness
• Feelings of hopelessness, pessimism
• Difficulty thinking, concentrating, remembering or making decisions
• Thoughts of death or suicide or attempts at suicide
• Loss of interest or pleasure in hobbies and activities that were once enjoyed
• Decreased energy, fatigue, feeling "slowed down" or sluggish
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive problems, and chronic pain

Not all patients will present every symptom, and the severity of symptoms will vary widely among individuals. Symptoms must, however, persist for at least two weeks before being considered a potential sign of depression, with the exception of suicidal thoughts or attempts.

Diagnosis of clinical depression in children is more difficult than in adults and is often left undiagnosed, and thus untreated, because the symptoms in children are often written off as normal childhood moodiness. Diagnosis is also made difficult because children are more likely than adults to show different symptoms depending on the situation.

While some children still function reasonably well, most who are suffering depression will suffer from a noticeable change in their social activities and life, a loss of interest in school and poor academic performance, and possibly drastic changes in appearance. They may also begin abusing drugs and/or alcohol, particularly past the age of 12. Although much rarer than in adults, children with major depression may attempt suicide or have suicidal thoughts even before the age of twelve.

 Diagnosis

Before a diagnosis of depression is made, a physician should perform a complete medical exam to rule out any possible physical cause for the suspected depression. If no such cause is found, a psychological evaluation should be done by the physician or by referral to a psychiatrist or psychologist. The evaluation will include a complete history of symptoms, a discussion of alcohol and drug use, and whether the patient has had or is having suicidal thoughts or thinking about death. The evaluation will also include a family medical history to see if other family members suffer from any form of depression or similar mood disorder.

There are several criteria lists and diagnostic tools that can also aid in the diagnosis of depression. Most are based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which is a book published by the American Psychiatric Association that defines the criteria used to diagnose various mental disorders, including depression.

The Beck Depression Inventory, originally created by Dr. Aaron T. Beck in 1961, is a 21-question patient completed survey that covers items related to the basic symptoms of depression, such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. The Beck Inventory is one of the most widely used diagnostic tools for self-diagnosis of depression, although its primary purpose is not the diagnosis of depression, but determining the severity and presence of symptoms.

There are also two Patient Health Questionnaires available that are also self-administered questionnaires. The PHQ-2 has only two questions that asks about the frequency of depressed mood and a loss of interest in doing things, with a positive to either question indicating the need for further testing.The PHQ-9 is a slightly more detailed nine question survey covering some of the major symptoms of depression and the frequency a person has experienced them. It is based directly on the diagnostic criteria listed in the DSM-IV and often used as a follow up to a positive PHQ-2 test.

Epidemiology

Clinical depression affects about 8–17% of the population on at least one occasion in their lives, before the age of 40. In some countries, such as Australia, one in four women and one in six men will suffer from depression. In Canada, major depression affects approximately 1.35 million people^{[citation needed]}, and in the USA approximately 14 million adults per year.An estimated 121 million people worldwide currently suffer from depression.

People who have had one episode of depression may be more than normally likely to have more episodes in the future, so the first time a young person becomes depressed is important both as a personal and public health concern.

About twice as many females as males report or receive treatment for clinical depression, though this imbalance is shrinking over the course of recent history; this difference seems to completely disappear after the age of 50–55. Clinical depression is currently the leading cause of disability in North America, and is expected to become the second leading cause of disability worldwide (after heart disease) by the year 2020, according to the World Health Organization.

Recent studies suggest that the diagnostic criteria for depression are far too broad, resulting in diagnosis of clinical depression in people who are not truly clinically depressed and who have shown normal responses to negative events.

Types

The diagnostic category major depressive disorder appears in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The term is generally not used in countries which instead use the ICD-10 system, but the diagnosis of depressive episode is very similar to an episode of major depression. Clinical depression also usually refers to acute or chronic depression severe enough to need treatment. Minor depression is a less-used term for a subclinical depression that does not meet criteria for major depression but where there are at least two symptoms present for two weeks.

 Major depression

Major depression is a severely depressed mood that persists for at least two weeks. Episodes may be isolated or recurrent and categorized as mild, major or severe. If the patient has already had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is usually made instead. Depression without periods of elation or mania is therefore sometimes referred to as unipolar depression because the mood remains at one emotional state or "pole". The diagnosis usually excludes cases where the symptoms are a normal result of bereavement (though it is possible for normal bereavement to turn into a depressive episode).

Diagnosticians recognize several possible subtypes of major depression:

• Depression with melancholic features – melancholia is characterized by a loss of pleasure (anhedonia) 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, anorexia (excessive weight loss, not to be confused with Anorexia Nervosa), or excessive guilt.

• Depression with atypical features – atypical depression is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite ("comfort eating"),^[14] excessive sleep or somnolence (hypersomnia), leaden paralysis, or significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection. Contrary to its name, atypical depression is the most common form of depression.

• Depression with Psychotic Features – Some people with major depressive or manic episodes may experience psychotic features. They may be presented with hallucinations or delusions that are either mood-congruent (content coincident with depressive themes) or non-mood-congruent (content not coincident with depressive themes). It is clinically more common to encounter a delusional system as an adjunct to depression than to encounter hallucinations, whether visual or auditory.

It is possible for a person to have a combination of these subtypes. For instance someone may experience loss of pleasure in activities as seen in melancholic depression in addition to over-eating and weight gain common to atypical depression.

 Other disorders featuring depressed mood

• Dysthymia is a chronic, mild depression in which a person suffers from a depressive mood almost daily over a span of at least two years without episodes of major depression. The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to co-occurring episodes of major depression (sometimes referred to as "double depression").^{[citation needed]}

• Bipolar disorder is an episodic illness characterized by alternating states of mania, hypomania and depression. In the United States, bipolar disorder was previously called "manic depression", however this term is no longer favored by the medical community.

• Postnatal depression or postpartum depression is a form of clinical depression that occurs after childbirth. Postnatal depression primarily occurs in women, less commonly in men, with similar symptoms and treatment methods as clinical depression, however postnatal depression generally lasts only a few weeks with proper diagnosis and treatment.

• Recurrent brief depression (RBD) is distinguished from clinical depression primarily by differences in duration. Patients with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2–3 days. Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle. People with clinical depression can develop RBD, and vice versa, with both illnesses having similar risks.

 Overlapping psychological features

 Anxiety

The different types of depression and anxiety are classified separately by the DSM-IV-TR, with the exception of hypomania, which is included in the bipolar disorder category. Despite the different categories, depression and anxiety can indeed be co-occurring (occurring together), independently (without mood congruence), or comorbid (occurring together, with overlapping symptoms, and with mood congruence). In an effort to bridge the gap between the DSM-IV-TR categories and what clinicians actually encounter, experts such as Herman Van Praag of Maastricht University have proposed ideas such as anxiety/aggression-driven depression.This idea refers to an anxiety/depression spectrum for these two disorders, which differs from the mainstream perspective of discrete diagnostic categories.

Although there is no specific diagnostic category for the comorbidity of depression and anxiety in the DSM or ICD, the National Comorbidity Survey (US) reports that 58 percent of those with major depression also suffer from lifetime anxiety. Supporting this finding, two widely accepted clinical colloquialisms include

• Agitated depression - a state of depression that presents as anxiety and includes akathisia (heightened restlessness), suicide, insomnia (not early morning wakefulness), nonclinical (meaning "doesn't meet the standard for formal diagnosis") and nonspecific panic, and a general sense of dread.

• Akathitic depression - a state of depression that presents as anxiety or suicidality and includes akathisia but does not include symptoms of panic. Some consider it a form of mixed state.

It is also clear that even mild anxiety symptoms can have a major impact on the course of a depressive illness, and the commingling of any anxiety symptoms with the primary depression is important to consider. A pilot study by Ellen Frank et al., at the University of Pittsburgh, found that depressed or bipolar patients with lifetime panic symptoms experienced significant delays in their remission.^{[citation needed]} These patients also had higher levels of residual impairment, or the ability to get back into the swing of things. On a similar note, Robert Sapolsky of Stanford University and others also argue that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically. To that point, a study by Heim and Nemeroff et al., of Emory University, found that depressed and anxious women with a history of childhood abuse recorded higher heart rates and the stress hormone ACTH when subjected to stressful situations.

 Hypomania

Hypomania, as the name suggests, is a state of mind or behavior that is "below" (hypo) mania. In other words, a person in a hypomanic state often displays behavior that has all the hallmarks of a full-blown mania (e.g., marked elevation of mood that is characterized by euphoria, overactivity, disinhibition, impulsivity, a decreased need for sleep, hypersexuality), but these symptoms, though disruptive and seemingly out of character, are not so pronounced as to be considered a diagnosably manic episode. In a psychiatric context, it is important to identify the possible presence and characteristics of manic and hypomanic episodes, since these may lead to a diagnosis of bipolar disorder, which is medically treated differently from depression.

Another important point is that hypomania is a diagnostic category that includes both anxiety and depression. It often presents as a state of anxiety that occurs in the context of a clinical depression. Patients in a hypomanic state often describe a sense of extreme generalized or specific anxiety, recurring panic attacks, night terrors, guilt, and agency (as it pertains to codependence and counterdependence). All of this happens while they are in a state of retarded or somnolent depression. This is the type of depression in which a person is lethargic and unable to move through life. The terms retarded and somnolent are shorthand for states of depression that include lethargy, hypersomnia, a lack of motivation, a collapse of ADLs (activities of daily living), and social withdrawal. This is similar to the shorthand used to describe an "agitated" or "akathitic" depression.

In considering the hypomania-depression connection, a distinction should be made between anxiety, panic, and stress. Anxiety is a physiological state that is caused by the sympathetic nervous system. Anxiety does not need an outside influence to occur. Panic is related to the "fight or flight" mechanism. It is a reaction, induced by an outside stimulus, and is a product of the sympathetic nervous system and the cerebral cortex. More plainly, panic is an anxiety state that we are thinking about. Finally, stress is a psychosocial reaction, influenced by how a person filters nonthreatening external events. This filtering is based on one's own ideas, assumptions, and expectations.

 Causes

Current theories regarding the risk factors and causes of clinical depression can be broadly classified into two categories, Physiological and Sociopsychological:

 Physiological

 Genetic predisposition

The tendency to develop depression may be inherited: according to the National Institute of Mental Health there is some evidence that depression may run in families. Most experts believe that both biological and psychological factors play a role.

Brain chemicals called neurotransmitters allow electrical signals to move from the axon of one nerve cell to the neuron of another. A shortage of neurotransmitters impairs brain communication.

Neurological

Many modern antidepressant drugs change levels of certain neurotransmitters, namely serotonin and norepinephrine (noradrenaline). However, the relationship between serotonin, SSRIs, and depression is typically greatly oversimplified when presented to the public, though this may be due to the lack of scientific knowledge regarding the mechanisms of action. Evidence has shown the involvement of neurogenesis in depression, though the role is not exactly known. Recent research has suggested that there may be a link between depression and neurogenesis of the hippocampus. This horseshoe-shaped structure is a center for both mood and memory. Loss of neurons in the hippocampus is found in depression and correlates with impaired memory and dysthymic mood. The most widely accepted explanation for this is that the drugs increase serotonin levels in the brain which in turn stimulate neurogenesis and therefore increase the total mass of the hippocampus and would in theory restore mood and memory, therefore assisting in the fight against the mood disorder. However, whether environmental confounds could contribute to this remains a subject of controversy.^{[citation needed]}

In about one-third of individuals diagnosed with attention-deficit hyperactivity disorder (ADHD), a disorder widely believed to be neurological and developmental, depression is recognized as comorbid. Dysthymia, a form of chronic, low-level depression, is particularly common in adults with undiagnosed ADHD who have encountered years of frustrating ADHD-related problems with education, employment, and interpersonal relationships.

New evidence shows that individuals with clinical depression exhibit markedly higher levels of monoamine oxidase A (MAO-A) in the brain compared to people without depression.MAO-A is an enzyme which reacts with and decreases the concentration of monoamines such as serotonin, norephinephrine and dopamine.

Medical conditions

Certain illnesses, including cardiovascular disease, hepatitis, mononucleosis, hypothyroidism, fructose malabsorption, sleep apnea, and organic brain damage caused by degenerative conditions such as Parkinson disease, Multiple Sclerosis or by traumatic blunt force injury may contribute to depression, as may certain prescription drugs such as hormonal contraception methods and steroids. Depression also occurs in patients with chronic pain, such as chronic back pain, much more frequently than in the general population. Fibromyalgia Syndrome sufferers also experience depression and anxiety. Dampness or mold in the home is associated with depression, as is the frequent use of aerosols and air fresheners in the home.

 Dietary

Poor diet has been linked with depression. An imbalanced diet or a diet that does not provide enough calories can worsen or induce depression. Excessive consumption of sugar has been proven to alter peoples moods (causing a 'rush' or 'high', hyperactivity and subsiquent deterioration of mood for exapmple, iritability), such consumption can be detremental regarding the mood changes experienced in depressive conditions. Alcoholic beverages have ethanol in them which is a psychoactive drug. It is a depressant. If included to a diet in large quantities it can induce depression. If it is introduced into the diet of a person who is already a depressive, comaratively little can greatly worsen depression both in the short and longer term.

Sleep quality

Poor sleep quality co-occurs with major depression. Major depression leads to alterations in the function of the hypothalamus and pituitary causing excessive release of cortisol which can lead to poor sleep quality. Individuals suffering from major depression have been found to have an abnormal sleep architecture, often entering REM sleep sooner than usual, along with highly emotionally-charged dreaming. Antidepressant drugs, which often function as REM sleep suppressants, may serve to dampen abnormal REM activity and thus allow for a more restorative sleep to occur.

 Seasonal affective disorder

Seasonal affective disorder (SAD) is a type of depressive disorder that occurs in the winter when daylight hours are short. It is believed that the body's production of melatonin, which is produced at higher levels in the dark, plays a major part in the onset of SAD and that many sufferers respond well to bright light therapy, also known as phototherapy.^{[citation needed]}

 Postpartum depression

Postpartum depression refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which has incidence rate of 10-15%, typically sets in within three months of labor and can last for as long as three months. About two new mothers out of a thousand experience the more serious depressive disorder Postnatal Psychosis which includes hallucinations and/or delusions.

Sociological

 Psychological factors

Low self-esteem and self-defeating or distorted thinking are connected with depression. However, it has been proposed that it is the result of depression and not necessarily the cause of it. This is still debated in the scientific community. Although it is not clear which is the cause and which is the effect, it is known that depressed persons who are able to make corrections in their thinking patterns can show improved mood and self-esteem (Cognitive Behavioral Therapy).^{[citation needed]} Psychological factors related to depression include the complex development of one's personality and how one has learned to cope with external environmental factors such as stress.^{[citation needed]}

 Early experiences

Events such as the death of a parent, issues with biological development, school related problems, abandonment or rejection, neglect, chronic illness, and physical, psychological, or sexual abuse can also increase the likelihood of depression later in life. Post-traumatic stress disorder (PTSD) includes depression as one of its major symptoms.^{[citation needed]}

 Life experiences

The following experiences or circumstances may trigger depression:

• divorce or the end of a serious relationship
• financial difficulties or poverty
• gambling addiction
• eating disorders
• grief over the death of a child, spouse or other family member
• job loss or unemployment
• loss of religious faith
• rape
• trauma
• sexual difficulties
• work-related stress

 Treatment and services

The treatment of depression is highly individualized to the patient, based on the patient's unique combination of biological, psychological and social health factors and the severity of their condition.^[ The three most conventional treatments for depression include medication, psychotherapy, and Electroconvulsive therapy, however new treatments and less conventional options are also available, including self help, life style changes, and vagus nerve stimulation.

If there is an imminent threat of suicide or the patient is a danger to others, hospitalization is employed as an intervention method to keep at-risk individuals safe until they cease to be a danger to themselves or others. At-risk individuals may also be placed in a partial hospitalization therapy, in which the patient sleeps at home but spends most of the day in a psychiatric hospital setting. This intensive treatment usually involves group therapy, individual therapy, medication management, and is used often in the case of children and adolescents.

 Drug therapy

Sufferers of severe depression may benefit from the use of antidepressant drugs. A widely-reported meta-analysis combined 35 clinical trials submitted to the FDA before licensing of four newer antidepressants. The authors found that although the antidepressants were statistically superior to placebo they often did not exceed the NICE criteria for a 'clinically significant' effect. In particular they found that the effect size was very small for moderate depression but increased with severity reaching 'clinical significance' for very severe depression.This result is consistent with the earlier clinical studies where only patients with severe depression benefited from the treatment with a tricyclic antidepressant imipramine or from psychotherapy more than from the placebo treatment. Selective serotonin reuptake inhibitors, such as escitalopram oxalate (Lexapro), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), are the primary medications considered for patients, having fewer side effects than the older monoamine oxidase inhibitors (MAOIs). MAOIs may be the best medication for a small number of patients, however those patients will have to avoid a variety of foods and decongestant medications to reduce the chances of a hypertensive crisis. Bupropion (Wellbutrin, Zyban), an atypical antidepressant that acts as a norepinephrine and dopamine reuptake inhibitor, is also considered to be effective in the treatment of depression, without sexual dysfunction or sexual side effects and without weight gain. Bupropion has also been shown to be more effective than SSRIs at improving symptoms such as hypersomnia and fatigue in depressed patients.

A patient's doctor may have to change the antidepressant taken, adjust the dosages of medications, or try different combinations of antidepressants before finding the most effective option for the patient; response rates to the first agent administered may be as low as 50%. It may take anywhere from 3 to 8 weeks after the start of medication before its therapeutic effects can be fully discovered. Patients are generally advised not to stop taking an antidepressant suddenly and to continue its use for at least four months to prevent the chance of recurrence. For patients that have chronic depression, medication may need to be continued for the remainder of their life.