Depressive disorder, frequently referred to simply as depression, is more than just feeling sad or going through a rough patch. It’s a serious mental health condition that requires understanding and medical care. Left untreated, depression can be devastating for those who have it and their families. Fortunately, with early detection, diagnosis and a treatment plan consisting of medication, psychotherapy and healthy lifestyle choices, many people can and do get better.

Some will only experience one depressive episode in a lifetime, but for most, depressive disorder recurs. Without treatment, episodes may last a few months to several years.

More than 17 million U.S. adults—over 7% of the population—had at least one major depressive episode in the past year. People of all ages and all racial, ethnic and socioeconomic backgrounds experience depression, but it does affect some groups more than others.

Symptoms

Depression can present different symptoms, depending on the person. But for most people, depressive disorder changes how they function day-to-day, and typically for more than two weeks. Common symptoms include:

• Changes in sleep
• Changes in appetite
• Lack of concentration
• Loss of energy
• Lack of interest in activities
• Hopelessness or guilty thoughts
• Changes in movement (less activity or agitation)
• Physical aches and pains
• Suicidal thoughts

Causes

Depression does not have a single cause. It can be triggered by a life crisis, physical illness or something else—but it can also occur spontaneously. Scientists believe several factors can contribute to depression:

• Trauma. When people experience trauma at an early age, it can cause long-term changes in how their brains respond to fear and stress. These changes may lead to depression.
• Genetics. Mood disorders, such as depression, tend to run in families.
• Life circumstances. Marital status, relationship changes, financial standing and where a person lives influence whether a person develops depression.
• Brain changes. Imaging studies have shown that the frontal lobe of the brain becomes less active when a person is depressed. Depression is also associated with changes in how the pituitary gland and hypothalamus respond to hormone stimulation.
• Other medical conditions. People who have a history of sleep disturbances, medical illness, chronic pain, anxiety and attention-deficit hyperactivity disorder (ADHD) are more likely to develop depression. Some medical syndromes (like hypothyroidism) can mimic depressive disorder. Some medications can also cause symptoms of depression.
• Drug and alcohol misuse. 21% of adults with a subtance use disorder also experienced a major depressive episode in 2018. Co-occurring disorders require coordinated treatment for both conditions, as alcohol can worsen depressive symptoms.

Diagnosis

To be diagnosed with depressive disorder, a person must have experienced a depressive episode lasting longer than two weeks. The symptoms of a depressive episode include:

• Loss of interest or loss of pleasure in all activities
• Change in appetite or weight 
• Sleep disturbances
• Feeling agitated or feeling slowed down
• Fatigue
• Feelings of low self-worth, guilt or shortcomings
• Difficulty concentrating or making decisions
• Suicidal thoughts or intentions

Treatments

Although depressive disorder can be a devastating illness, it often responds to treatment. The key is to get a specific evaluation and treatment plan. Safety planning is important for individuals who have suicidal thoughts. After an assessment rules out medical and other possible causes, a patient-centered treatment plans can include any or a combination of the following:

• Psychotherapy including cognitive behavioral therapy, family-focused therapy and interpersonal therapy.
• Medications including antidepressants, mood stabilizers and antipsychotic medications.
• Exercise can help with prevention and mild-to-moderate symptoms.
• Brain stimulation therapies can be tried if psychotherapy and/or medication are not effective. These include electroconvulsive therapy (ECT) for depressive disorder with psychosis or repetitive transcranial magnetic stimulation (rTMS) for severe depression.
• Light therapy, which uses a light box to expose a person to full spectrum light in an effort to regulate the hormone melatonin.
• Alternative approaches including acupuncture, meditation, faith and nutrition can be part of a comprehensive treatment plan.

Reviewed August 2017

Many treatment options are available for depression, but how well treatment works depends on the type of depression and its severity. For most people, psychotherapy and medications give better results together than either alone, but this is something to review with your mental health care provider.

Psychotherapy

Psychotherapy (or talk therapy) has an excellent track record of helping people with depressive disorder. While some psychotherapies have been researched more than others, many types can be helpful and effective. A good relationship with a therapist can help improve outcomes.

Many clinicians are trained in more than one kind of psychotherapy, so ask your clinician what kind of psychotherapy they practice and how it can help you. A few examples include:

• • Cognitive behavioral therapy (CBT) has a strong research base to show it helps with symptoms of depression. This therapy helps assess and change negative thinking patterns associated with depression. The goal of this structured therapy is to recognize negative thoughts and to teach coping strategies. CBT is often time-limited and may be limited to 8–16 sessions in some instances.

• • Interpersonal therapy (IPT) focuses on improving problems in personal relationships and other changes in life that may be contributing to depressive disorder. Therapists teach individuals to evaluate their interactions and to improve how they relate to others. IPT is often time-limited like CBT.

• Psychodynamic therapy is a therapeutic approach rooted in recognizing and understanding negative patterns of behavior and feelings that are rooted in past experiences and working to resolve them. Looking at a person’s unconscious processes is another component of this psychotherapy. It can be done in short-term or longer-term modes.

Psychoeducation And Support Groups

Psychoeducation involves teaching individuals about their illness, how to treat it and how to recognize signs of relapse. Family psychoeducation is also helpful for family members who want to understand what their loved one is experiencing.

Support groups, meanwhile, provide participants an opportunity to share experiences and coping strategies. Support groups may be for the person with the mental health condition, for family/friends or a combination of both. Mental health professionals lead some support groups, but groups can also be peer-led.

Explore NAMI’s nationwide offerings of free educational programs and support groups that provide outstanding education, skills training and support.

Medications

For some people, antidepressant medications may help reduce or control symptoms. Antidepressants often take 2-4 weeks to begin having an effect and up to 12 weeks to reach full effect. Most people will have to try various doses or medications to find what works for them. Here are some antidepressants commonly used to treat depression:

Selective serotonin reuptake inhibitors (SSRIs) act on serotonin, a brain chemical. They are the most common medications prescribed for depression.

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Citalopram (Celexa)
• Escitalopram (Lexapro)

​Serotonin and norepinephrine reuptake inhibitors (SNRIs) are the second most common antidepressants. These medications increase serotonin and norepinephrine.

• Venlafazine (Effexor)
• Desvenlafazine (Pristiq)
• Duloxetine (Cymbalta)

Norepinephrine-dopamine reuptake inhibitors (NDRIs) increase dopamine and norepinephrine. Bupropion (Wellbutrin) is a popular NDRI medication, which causes fewer (and different) side effects than other antidepressants. For some people, bupropion causes anxiety symptoms, but for others it is an effective treatment for anxiety.

Mirtazapine (Remeron) targets specific serotonin and norepinephrine receptors in the brain, thus indirectly increasing the activity of several brain circuits. Mirtazapine is used less often than newer antidepressants (SSRIs, SNRIs and bupropion) because it is associated with more weight gain, sedation and sleepiness. However, it appears to be less likely to result in insomnia, sexual side effects and nausea than the SSRIs and SNRIs.

• Bupropion (Wellbutrin)
• Mirtazapine (Remeron)

Second-generation antipsychotics (SGAs), or “atypical antipsychotics,” treat schizophrenia, acute mania, bipolar disorder and bipolar mania and other mental illnesses. SGAs can be used for treatment-resistant depression.

• Aripiprazole (Abilify)
• Quetiapine (Seroquel)

Tricyclic antidepressants (TCAs) are older medications, seldom used today as initial treatment for depression. They work similarly to SNRIs but have more side effects. They are sometimes used when other antidepressants have not worked. TCAs may also ease chronic pain.

• Amitriptyline (Elavil)
• Desipramine (Norpramin)
• Doxepin (Sinequan)
• Imipramine (Tofranil)
• Nortriptyline (Pamelor, Avantyl)
• Protriptyline (Vivactil)

Monoamine oxidase inhibitors (MAOIs) are less used today because newer, more effective medications with fewer side effects have been found. These medications can never be used in combination with SSRIs. MAOIs can sometimes be effective for people who do not respond to other medications.

• Phenelzine (Nardil)
• Isocarboxazid (Marplan)
• Tranylcypromine Sulfate (Parnate)
• Selegiline patch (Emsam)

Brain Stimulation Therapies

For some, brain stimulation therapies may be effective, typically after other treatments have not been effective.

• • Electroconvulsive Therapy (ECT) involves transmitting short electrical impulses into the brain. ECT does cause some side effects, including memory loss. Individuals should understand the risks and benefits of this intervention before beginning a treatment trial.

• • Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new type of brain stimulation that uses a magnet instead of an electrical current to activate the brain. It is not effective as a maintenance treatment.

• Vagus Nerve Stimulation (VNS) has a complex history. For a fuller understanding of this treatment, read the NIMH summary of this and other brain stimulation interventions.

Complementary And Alternative Medicine (CAM)

Relying solely on CAM methods is not enough to treat depression, but they may be useful when combined with psychotherapy and medication. Discuss your ideas of CAM interventions with your health care professional to be sure they will not cause side effects or adverse reactions.

The National Center for Complementary and Integrative Health reviews research on complementary treatments. You can search for each intervention on their website.

• • Exercise. Studies show that aerobic exercise can help treat mild depression because it increases endorphins and stimulates norepinephrine, which can improve a person’s mood.

• • Folate. Some studies have shown that when people with depression lack folate (also called folic acid or vitamin B9), they may not be receiving the full benefit from any antidepressants they may be taking. Studies suggest that in some situations taking L-methylfolate (an active form of folate) can be an additional treatment with other psychiatric medications.

• St John’s Wort. This supplement has similar chemical properties to some SSRIs. Risks of combining St John’s Wort with SSRIs and other medications are well-known and substantial.

Experimental Treatments

These following treatments are not FDA-approved but are being researched:

• • Ketamine. Ketamine, which may offer a new model in treating depression, may have potentially quick and short-term impact on depression and suicidal thoughts. Ketamine is an anesthetic with a street value (special K) that has not been studied for long-term use. It can make psychosis worse and is not an ideal choice for people with substance use disorders.

• Deep Brain Stimulation. This treatment has been used to treat Parkinson’s disease. See the NIMH page on brain stimulation for more information.

Reviewed August 2017

Coping with depression isn’t easy, but if you, a family member or a friend is struggling, there is help. NAMI is there to provide support and resources for you and your family.

Helping Yourself

Leading a balanced lifestyle can help you manage symptoms of depression. Here are some suggestions from people who have lived experience with depression:

Learn all you can. Learn about the many treatment options available. Connect with other people experiencing depression in support groups or meetings. Attend local conferences and conventions. Build a personal library of useful websites and helpful books.

Recognize early symptoms. Identify possible warning signs and triggers that may aggravate your depression symptoms. With this knowledge, you can recognize an emerging episode and get the help you need as soon as possible. Don’t be afraid to ask your friends and family for help—they can help you monitor your symptoms and behavior.

Partner with your health care providers. Give your health care provider all the information he or she needs to help you recover—including any reactions to medications, your symptoms or any triggers you notice. Develop trust and communicate openly.

Know what to do in a crisis. Be familiar with your community’s crisis hotline or emergency walk-in center. Know how to contact them and keep the information handy.

Find emotional support from others who experience depression. Share your story, thoughts, fears and questions with other people who have the same condition. Connect through online message boards or peer-education programs like NAMI Peer-to-Peer or support groups like NAMI Connection.

Avoid drugs and alcohol. These substances can disturb emotional balance and interact with medications. You may think using alcohol or drugs will help you feel better, but using them can hinder your recovery or make symptoms worse.

Get physically healthy. Eat well and exercise. To relieve stress, try activities like meditation, yoga or Tai Chi.

Helping A Family Member Or Friend

When someone you love and care about experiences the symptoms of mental illness, you face unique challenges yourself, including complex family dynamics, social isolation and often unpredictable behavior. Getting support for yourself is essential for you to be able to be helpful for the person you care about.

Learn more about your loved one’s condition. Learning about the condition your loved one experiences will help you better understand and support them. Read personal accounts of lived experience, full of tips and advice on the NAMI Blog:

• Depression is an Illness, Not a Weakness
• Living with Depression: How to Keep Working

Recognize early symptoms. Depression often has warning signs, such as a low mood, feeling fatigued or having trouble sleeping. Discuss your friend or family member’s past episodes with them to help them improve their ability to recognize the signs early.

Communicate. Speak honestly and kindly. Don’t scold or blame people with depression or urge them to “try harder” to “just be happy.” Instead, make specific offers of help and follow through with those offers. Tell the person you care about them. Ask them how they feel and truly listen.

React calmly and rationally. Even if your family member or friend is in a crisis, it’s important to remain calm. Listen to their concerns and make them feel understood—then take the next step toward getting help.

Find emotional support from others. Share your thoughts, fears and questions with other people who have loved ones with similar conditions. Connect with others through online message boards or NAMI peer-education programs.

Reviewed August 2017

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