Depression

*The information on this website is not intended to diagnose, treat, cure or prevent any disease.

What is Depression?

Depression is an incredibly common condition which negatively impacts how people feel, think, and behave. It can range greatly in severity, and in some instances can be normal, such as when grieving. In severe cases of depression, people may have suicidal thoughts or urges, or feel the need to harm themselves in other ways. Serious depression can be debilitating, and result in poor self-care, loss of productivity, lack of socialization, and can sometimes lead to a self-perpetuating cycle.

In the United States, major depression is one of the most common psychiatric problems, with nearly 7% of adults affected with at least one episode lasting greater than 2 weeks in 2016. It is more common in women than in men, and affects the 18 to 25 year-old age group the most. Multi-racial people seem to be at higher risk as well. The lifetime risk of experiencing depression at least once is also quite high at around 16%. Women are at the highest risk, with nearly 1/3 experiencing depression in their lifetimes.

There are different forms of depression which may occur under specific circumstances, such as postpartum depression, seasonal affective disorder (SAD), or psychotic depression. Depending on the specific circumstances or triggers for depression, different therapeutic avenues may be applicable.

Common Symptoms

The severity of depression symptoms can range from mild to severe. It is important to remember that many of these feelings may be normal for short periods of time. Clinical depression is a condition that lasts at least 2 weeks or more. Symptoms may be different for everyone. Common symptoms of depression include:

Feeling empty, sad, or that life has no meaning
Anhedonia (loss of feelings of pleasure, even in activities which used to be enjoyed)
Fatigue
Sleep disturbances (either sleeping more, sleeping less, or repeatedly waking up in the night)
Appetite changes (either eating more, compulsively eating, or eating much less or requiring encouragement to eat)
Rapid weight gain or loss
Suicidal thoughts, planning, or even attempts
Ruminating on negative thoughts
Slowed speaking or loss of affect
Irritability
Mysterious pain without clear origins, such as joint, muscle, abdominal pain, or headaches
Purposeless activity such as hand-wringing, pacing, pulling hair
Lack of eye contact
Poor concentration
Difficulty in abstract thinking

Diagnosis

Depression typically does not require diagnostic testing to diagnose, however it is important to consider that depression may occur in conjunction with other illnesses, particularly those that can have a strong psychological impact, such as cancer or heart disease. Most physicians, psychiatrists, and psychotherapists will be able to diagnose depression through talking to their patients and identifying behavioral patterns or signs such as those listed under “Common Symptoms”.

That said, a physician may ask you to fill out a standardized questionnaire which can be helpful in establishing the severity of depression, as well as tracking your response to therapy. They may also recommend certain tests to make sure there is not an underlying cause of your depression, such as hormonal imbalances or vitamin deficiencies. If your depression accompanies other clinical signs of disease, your physician may recommend tests specific for those conditions as well.

Surveys may be self-reported or evaluated by a physician. Examples include (but are not limited to):

Quick Inventory of Depressive Symptomatology (QIDS): This is a short, 16 question survey which provides an overall score to help determine the severity of depressive symptoms.
Inventory of Depressive Symptomatology (IDS):This is a longer version of the QIDS survey listed above. Rather than 16 questions, this is a 30-question survey which provides similar information to establish a “score” and gauge severity of depression. Both surveys are clinically-validated.
The Hamilton Rating Scale for Depression (HAM-D): A commonly used scale to assess patient response to therapy. This scale has been used more than any others to evaluate the efficacy of prescription anti-depressant medications.

Common diagnostic tests a physician may order include:

Complete Blood Count and Serum Chemistry: These are basic tests which evaluate for anemia, high or low white blood cell counts, liver, kidney function, and electrolytes
Vitamin D and/or calcium levels: Low vitamin D is associated with many different health issues, and may play a role in seasonal affective disorder
Thyroid levels: Low circulating thyroid levels are often associated with depressive symptoms.

Other tests may be based upon other unique symptoms a patient may be displaying, such as neurologic signs, or signs which raise concerns for things like cancer or infectious diseases. Other diagnostics that do not apply to everyone but may be conducted include:

Advanced imaging (such as CT or MRI)
Infectious Disease Testing (Lyme, Epstein-Barr, etc.)
Cancer Screening (Bloodwork, Imaging, Biopsies)

Treatment Options

Treatment for depression will depend greatly on individual patient, and not every approach can be applied to all patients. Some patients may benefit greatly from anti-depressant medications, while medication may not be appropriate or effective for others. Often, a combination of pharmaceutical approaches and non-pharmaceutical approaches are used in the management of depression. As there are many non-pharmaceutical supplements which have neurotransmitter activity, it is always important to discuss with a doctor what combinations can be safely used together. Many pharmaceutical and non-pharmaceutical options modulate serotonin in the brain, and using these agents in combination can result in a serious and possibly fatal condition called “serotonin syndrome.”

Pharmaceuticals and Medical Procedures:

There are now many different drugs available to manage depression, and patients respond differently to many of these drugs. It may require some trial and error to determine which medication or dose works best for each individual patient. It is important to follow-up with your doctor and have patience while the right dose and medication is found. It is possible, especially in teenagers, that anti-depressants can increase the risk of suicide or result in suicidal thoughts. If you experience these thoughts or urges after beginning on of these medications, it is important to realize that it may be an effect of the medication and speak with your doctor.

Antidepressants
- Selective serotonin reuptake inhibitors (SSRIs): This is perhaps the most commonly prescribed class of antidepressants, and includes drugs like Prozac (fluoxetine), Zoloft (sertraline), Lexapro (escitalopram), and Paxil (paroxetine) among others. They are believed to work by increasing serotonin levels in the brain without impacting other neurotransmitters. Depending on your specific combination of symptoms, different SSRIs may be considered most appropriate. While some are specific for depression, others seem to work for depression and other issues like generalized anxiety disorder and obsessive-compulsive disorders. These medications can take weeks to begin showing effects. While they can be incredibly helpful to many people, they also often carry side effects which may make long-term therapy difficult, such as sexual dysfunction, weight gain, or feeling dull.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs): These drugs increase both norepinephrine and serotonin levels in the brain. Drugs in this class include Effexor (venlafaxine) and Cymbalta (duloxetine). These drugs can also cause a diverse range of side effects including sexual dysfunction, loss of appetite, fatigue, or difficulty sleeping.
- Tricyclic antidepressants: These are older and less frequently prescribed anti-depressants due to their undesirable side effect profile. However, in some patients they may be helpful for those who have not responded to other classes of medications. Examples include nortriptyline, amitriptyline, imipramine, doxepin, and desipramine.
- Monoamine oxidase inhibitors (MAOIs): These medications prevent the breakdown of norepinephrine, serotonin, and dopamine by the enzyme monoamine oxidase. Like tricyclic anti-depressants, they are often reserved for patients who are resistant to other treatments. Because this medication inhibits an important enzyme that degrades excessive neurotransmitters, it is important for patients on these medications to avoid foods which contain excessive tyramine (an amino) acid, which causes release of epinephrine and norepinephrine. Excessive tyramine levels can result in extremely elevated blood pressure, which can have serious consequences. Foods high in tyramine include fermented products such as alcoholic beverages and aged cheeses.
- Atypical Anti-depressants: This group of medications does not fit neatly into any of the previously mentioned categories, but they can be effective anti-depressants and some are commonly prescribed. Wellbutrin (bupropion) in particular, does not have sexual side effects and actually results in some weight loss in many patients, rather than weight gain. Other drugs include mirtazapine, trazodone, vilazodone, and vortioxetine.
Ketamine: This is a dissociative anesthetic drug which has shown promise in individuals with treatment-resistant depression. How it relieves depression is unclear. Currently, ketamine is only administered as an infusion in hospital, however a nasal spray is under development. It is a drug with potential for abuse, however.
Anti-psychotics or mood stabilizers: For people with psychotic issues or bi-polar disorder in conjunction with depression, these drugs may be prescribed alone or in addition to other medications.
- Lithium: This is a medication that has been traditionally used to treat bipolar disorder, but seems to be helpful in those with severe depression as well.
Levothyroxine: For people with low thyroid levels, thyroid hormone supplementation may be recommended. It is important to have thyroid levels monitored frequently to ensure that they do not become too elevated, which can result in many other health issues.
Electroconvulsive Therapy (ECT): This procedure passes electrical currents through the brain, which alters the function of neurotransmitters, relieving depression. This is typically used in people with treatment-resistant depression.
Transcranial Magnetic Stimulation (TMS): Magnetic pulses are transmitted into the brain, affecting neurotransmitter function. This therapy is also usually reserved for those who appear to be treatment-resistant
Management of other Concurrent Health Conditions: Whether hormonal, infectious, neurologic, or some other condition, addressing the primary problem may be the most important step in managing depression.

Non-pharmaceutical options:

There are a broach range of non-pharmaceutical options, and some, such as psychotherapy, may be more important/effect than medications, although many people find optimum benefit by combining these approaches.

Psychotherapy/Cognitive Behavioral Therapy: This is an extremely important component for many people managing severe depression. A therapist can help you identify and explore the causes of your depression, as well as help develop healthy coping mechanisms to break the cycle of depression.
Mind Body Techniques:
- Mindfulness/Meditation: Practicing mindfulness can be very helpful for many people who feel overwhelmed and depressed. This is a healthy coping mechanism which can be useful for self-exploration, introspection, and inducing a state of calmness. Guided meditation techniques can be useful for people trying to establish daily practice.
- Journaling: Keeping track of daily events and moods can provide an outlet for expressing emotions, rather than containing and dwelling upon them.
- Yoga: Providing exercise while simultaneously practicing focused techniques which are similar to meditation can help tremendously. As yoga is also often a group activity, this can also help provide socialization and support.
- Acupuncture: Acupuncture is applied to many health issues, and depression is one of them. May people find it helps induce states of relaxation. Some studies have found it more effective than counseling in people who have both pain and depression.
- Hypnotherapy: This can be helpful for some people who are open to it. The power of suggestion can be used to help improve or establish healthy habits or break the cycle of negative thoughts and emotions.
- Reflexology: This is a technique which applies pressure to various points on the feet. Some people find this is helpful for things ranging from chronic pain to depression.
- Guided Imagery: Similar to meditation, guided imagery encourages an individual to create a mental landscape of relaxation and peace. This can serve as a way to mentally escape and self-induce calmness and relaxation.
- Aerobic Exercise: Exercise is an important part of being healthy, and leads to release of adrenaline and other hormones which improve mood. Regular exercise can improve sleep patterns, increase self-esteem, and may be an important component in managing depression.
Supplements:
- Omega-3 fatty acids: Deficiencies in omega-3’s has been found in patients suffering from depression, and supplementation may be helpful in treatment.
- Vitamins D: Vitamin D may be associated with depression, especially those who are thought to be suffering from seasonal affective disorder.
- St. John’s Wort: This naturally-occurring herb has been long-used to treat depression, and it has decent scientific evidence to support it. It is believed to increase serotonin levels in the brain (possibly by functioning as an SSRI), and has been found in some studies to be as effective as the SSRI medication sertraline. However, St. John’s Wort may also be associated with the development of cataracts, and combination with some anti-depressant medications or other supplements may increase the risk of serotonin syndrome. It is recommended to discuss the use of St. John’s Wort with a doctor, even though it is over-the-counter.
- S-adenosyl-L-Methionine (SAMe): SAMe is an antioxidant and helps regulate the integrity of cell membranes. Small studies have found that it may be helpful in relieving depression. It is generally considered safe, but may interact with some anti-depressant medications.
- Magnesium: Magnesium supplementation may be helpful in the treatment of depression. Many people with depression are overall deficient, and there is abundant anecdotal evidence that it is helpful for some with depression. It is generally safe supplement, however those with kidney disease should be cautious.
- Lavender Oil/Silexan: Lavender has a well-known calming effect, and may be especially helpful for those who suffer from anxiety in combination with depression. A specific lavender oil extract (trade name Silexan) has been studied and found to be helpful in improving depression scores and seems to be as effective as the medication lorazepam (a benzodiazepine) at reducing anxiety.
- 5-Hydroxytryptophan: This is a precursor to serotonin which may be helpful in management of depression. Although there is some evidence that it is helpful, it should be used with caution, especially in combination with anti-depressant medications or St. John’s Wort as it may increase risk of serotonin syndrome.
- Ginkgo biloba: This has found some utility in people with a combination of depression and anxiety by inducing a calming effect. The mechanism is unclear, so like other supplements listed, be used cautiously in the presence of prescription medications.
- Acetyl-L-Carnitine: An amino acid found in meat, low levels have been found in those suffering from depression. Supplementation may be beneficial.
- DHEA: A naturally occurring hormone in the body which may be helpful in depression. This is an androgen, which is lower in depressed people, women and the elderly.
- Folic Acid:One of the B vitamins, something as simple as folic acid supplementation may be helpful in those with depression. It is safe and inexpensive, and should be considered in those with treatment-resistant depression.
- Lemon Balm:Similar to lavender oil, lemon balm has a calming effect and may be helpful in people with depression linked to anxiety issues.
- Phenylethylamine: This is a backbone to many neurotransmitters in the body and seems to be helpful for people with depression.
- L-phenylalanine: This is an amino acid which can be metabolized to phenylethylamine, serving as another source. People with a condition called phenylketonuria should not take this supplement as it can be dangerous.
- Rhodiola: A natural herb with reported anti-depressant effects
- Saffron: A spice with many reported effects, saffron has some evidence of being effective against depression as well.
- Turmeric/Curcumin: This powerful anti-inflammatory has many reported health effects and may be useful in the treatment of depression as well.
- Yohimbe: This is a naturally-occurring MAOI which can be useful for depression. Caution should be exercised, especially in combination with other anti-depressant medications as well as avoid alcohol and aged cheeses.
- Zinc: An important mineral, zinc has been found to be lower in people with depression, and there is evidence that supplementation can be helpful in relieving depressing, possibly suggesting some causality.
- Probiotics: Intestinal bacteria generate many compounds which either act directly as neurotransmitters or are later metabolized into neurotransmitters. Imbalance in gut bacteria can have detrimental impacts on the brain and psychology.
Psilocybin and other psychedelics: There is promising evidence that psilocybin, the active ingredient in “magic mushrooms” can be used to treat depression in people. Some very small studies have found that one or two well-controlled treatment sessions have resulted in long-lasting improvements in mood and feelings of well-being. Ayahuasca, a psychedelic brew used in religious ceremonies in South America, may have similar properties. In the United States, these drugs and compounds are considered Schedule I substances (illegal and without any approved medical use), however the FDA has recently approved clinical trials to examine the use of psilocybin in patients with treatment-resistant depression based on preliminary results by researchers at Johns Hopkins School of Medicine and at Imperial College London in the UK.
Aromatherapy: Essential oils can greatly improve relaxation and comfort in patients with depression by reducing stress.
Electromagnetic Field Therapy: Research has been conducted into electromagnetic fields and their impact on fatigue in lupus. Two trials have shown improvement in fatigue in patients with moderate clinical signs.
Massage therapy: This may improve relaxation, relieve anxiety, and improve mood in depressed patients.
Dietary Modifications:
- Avoid refined sugars and flours, minimize processed foods and meats, and butter. Increase overall intake of vegetables, seeds, nuts, and lean proteins like fish and yogurt.
- Anti-inflammatory diet
- Mediterranean Diet
Chelation therapy: Heavy metals may be linked to depression as well. Using compounds like EDTA and Succimer can help remove excess heavy metals from the body
Light therapy:Exposure to natural light or light spectrums that approximate natural sunlight can be effective treatments for depression linked to seasonal affective disorder (SAD).

Prevention

The best way to prevent depression is to take a holistic approach to your own health, and be cognizant of your biological, physical, and emotional needs. Mind-body techniques are useful before the onset of depression; these techniques can help you manage stress effectively before it becomes overwhelming. They also allow you your own time to reflect on issues and problems in your life, and give you opportunities to examine possible solutions or prioritize them. Try practicing daily meditation to improve your resistance to depression.

Physically, regular exercise will promote natural endorphins which elevate mood, and improved muscle composition and fat loss will also make you feel and look good, which are important for maintain mental health. Eating a well-balanced diet low in inflammatory compounds like refined sugars and flours will maintain whole-body health while providing a good balance of vitamins, minerals, and healthy fats, all of which are associated with depression in people. When possible, exercise outdoors in the daylight to increase sun exposure, which can help improve vitamin D levels and prevent seasonal affective disorder. If you live in an area without much sunlight for long stretches of the year, consider investing in a light box and using it in the winter months to help prevent seasonal affective disorder.

Be aware of your health and schedule visits with your doctor is something is not right or you are feeling unwell. This can be a sign of some other health issue which could manifest as depression. Also, keep your home environment clean and maintain your hygiene. Avoid mold, which is associated with a large number of health issues, and wash your hands to avoid communicable diseases.

Finally, always address your emotional needs. Everyone will experience stressful events, and having an outlet for emotions is important for maintaining emotional health. Whether it is a significant other, a therapist, or a journal, provide yourself a resource to discuss your own problems rather that feeling you must shoulder them by yourself. Many people find a therapist helpful even if they do not suffer from depression. Friends can also serve as therapists and provide solidarity in difficult times. Internet support groups can also be a great resource for those who may be limited in their ability to socialize, whether it is from disability or unusual working hours. Humans tend to need social interaction, and isolation and loneliness can lead to depression on their own.

Causes

There are a huge number of causes of depression, but all result in some disturbance to the body and mind. Triggers for depression can include sudden emotional events, like the loss of a loved one, being fired from a job, or a diagnosis with a major disease. All of these events are life-altering in some way, and it can be difficult to cope with a new reality. This alone results in depression for many otherwise-healthy people. People who are isolated by disability, lonely working conditions (like shift-workers, or people who work alone), or those who are entrusted to great responsibility or have high-stakes jobs are also at risk of depression. Chronic stress like marital issues and debt are also major causes of depression in the United States.

Sometimes, depression is associated with events that are traditionally viewed as happy events, like childbirth. Post-partum depression is very common in new mothers, whose bodies have just undergone a major biological event with huge swings in hormones, changes in physical appearance, and the new responsibility of caring for a human life. Often, the fact that new mothers are depressed leads to feelings of guilt, especially in the atmosphere of elated friends and relatives. This can perpetuate and exacerbate their depression.

Sometimes, traumatic events can result in chronic depression, even after the event has long passed. This is commonly seen in conjunction with post-traumatic stress disorder (PTSD). Although we commonly think of this occurring to soldiers returning from way, many people who have had to endure strong emotional events like rape, abuse, or life-threatening situations may also have PTSD. For many people, this may go undiagnosed for years if they never seek help.

Biologically, underlying health issues are also possible causes of depression. Hormonal problems like under-active thyroid glands, adrenal gland dysfunction, or diabetes mellitus can all lead to depression. If depression is the major manifestation of these conditions, they may be overlooked until more serious health problems surface. Fortunately, management of these conditions alone may help relieve depression, once proper hormonal balances are restored.

Situations which result in reduced exposure to sunlight or disturbances in sleeping patterns are also likely to induce depression. Seasonal affect disorder is commonly seen in regions further from the equator during the winter months. This may be partially-related to vitamin D, or just the importance of daylight in regulating our own biologic rhythms. People who work at night and sleep during the day are at higher risk of depression as well as many other health problems like high blood pressure, heart disease, and cancer.

Infectious diseases can be an insidious cause of depression that can be easily overlooked. The bacterium responsible for Lyme disease, Borrelia burgdorferi, is possible cause of depression. Many of the psychological disturbances seen in people with Lyme disease are also present in people with depression, and it is possible that Lyme disease may only manifest as depression in some people. There are also viral diseases which, often associated with a large number of diseases, could be associated with depression as well. Epstein-Barr virus, the suspected cause of mononucleosis, HIV, Herpes simplex, Borna disease virus, and varicella zoster virus (chickenpox), may all be linked to depression. These viruses may set up long-standing subclinical infections which result in increased inflammation throughout the body or in the nervous system, setting up for derangements in neurotransmitter function or production. Certain parasites can cause depression as well. They may lead to anemia, compete for nutrient absorption in the gut leading to nutritional deficiencies, or cause chronic inflammation.

The microbiome of the intestine is also important in the regulation of mental health. As mentioned before, a shift in the intestine from beneficial bacterial to detrimental bacteria can alter the production of neurotransmitters. This alone can result in depression. Eating foods rich in probiotics, especially if you are taking or recently took antibiotics, may be an important way to protect against depression.

Finally, insidious causes like heavy metal toxicity or mold exposure should be considered, particularly if you live in a contaminated home environment, have heavy metals such as lead in your municipal water, or have implants like amalgam fillings which can leak mercury into the blood stream. These issues are common and often not considered in a diagnosis of depression, but may play an important role and set up resistance to treatment.

Clinics for Management of Depression

Depression is very common. While there are many specialty centers, it is always wise to find doctors in your area who are accessible and convenient for you. It can be difficult to establish a relationship with doctors, and adding in distance and geography will make it harder for appropriate follow-up visits and long-term care. For those who cannot leave their homes or have unusual work schedules, there are many telemedicine options which provide access to therapists and psychiatrists.

Standard Clinics

Johns Hopkins Psychiatry and Behavioral Sciences

University of California San Francisco Psychiatry Clinic

McLean Hospital (Belmont, MA)

Massachusetts General Hospital

New York Presbyterian Hospital

Alternative Clinics

Clearview Women’s Center