Major Depressive Disorder (MDD), commonly referred to as major depression or just depression, is a common condition that affects ~6% of Australians in any one year (Commonwealth Department of Health and Aged Care, 2000).

To be diagnosed with major depression, a person must experience at least 2 weeks of depressed/low mood or loss of interest with at least four of the following symptoms nearly every day (American Psychiatric Association, 2000):

a change in appetite or a significant change in weight (an increase or decrease);
sleep problems;
psychomotor agitation or retardation (e.g. moving more slowly than usual);
fatigue or loss of energy;
feelings of worthlessness or of excessive or inappropriate guilt;
difficulty in thinking or in concentrating; or indecisiveness; and/or
recurrent thoughts of death, and/or thoughts about suicide or attempted suicide;

Anthony struggles with depression

Anthony, a 35-year-old accountant, has been feeling low for the last couple of months. He has lost interest in doing the things he used to enjoy. He finds that he spends most of his nights alone at home, and has withdrawn from his friends. He often feels tired but is unable to fall sleep at night and wakes up early in the morning, unable to fall sleep again. At work he has problems concentrating. Anthony feels like he’s in a deep, dark hole from which he can see no escape.

How is depression different from sadness?

Depression does not simply involve feeling a little low, having a bad day or feeling blue. In depression, the low mood and other associated symptoms do not go away after a day or two, but persist, often resulting in difficulties in coping with everyday life. This low mood is also very difficult to shift and is out of proportion to the surrounding circumstances or feels beyond a person’s control. A person with depression can often feel very overwhelmed by their symptoms and feelings. Depression is also commonly associated with feelings of worthlessness, thoughts about suicide and a number of physical symptoms not usually seen when a person is simply sad.

Who is affected by depression?

According to the American Psychiatric Association (2000):

Both males and females are affected by depression, although it is more common in females.
Depression occurs in all cultures. However, it can be experienced and communicated differently in different cultures (e.g. in some cultures depression is experienced mainly as somatic symptoms, such as headaches, weakness, problems of the heart).
Depression can begin at any age. The average age of onset is in the mid 20s.
Depression can affect people from all sections of society; however, it tends to be more common in socially excluded and economically disadvantaged groups, and their recovery tends to be slower.
Depression and anxiety symptoms often occur together. If the symptoms are relatively mild, a person is diagnosed with ‘mixed anxiety and depressive disorder’. When symptoms are more severe, a person is likely to have coexisting or comorbid anxiety and depression.

What causes depression?

There is no single cause of depression, and often a number of factors come together at a certain time to cause a depressive episode. For example, someone with a family history of depression (genetic vulnerability) might become depressed for the first time when their mother dies (a life event). The following are some of the factors that contribute to the onset of depression:

Genetics: As with many other conditions, a person’s vulnerability to depression is influenced by familial or genetic factors. Research to date suggests that there is no single gene associated with the onset of depression. Although a person may have a biological or genetic predisposition to developing depression, other factors also operate in order for this vulnerability to be realised.
Brain chemicals (Neurotransmitters): Neurotransmitters are chemical messengers in the brain which are involved in sending messages from one part of the brain to the other. There is scientific evidence that disturbances in the levels or the availability of some of these neurotransmitters may contribute to the development of depression.
Hormones: Generally, altered levels of brain-active hormones (e.g. cortisol, thyroxin, growth hormones and sex hormones) are known to influence mood and to be involved in depression.
Personality: Research into the links between personality and depression has identified a set of characteristics, such as independence, assertiveness, confidence, and optimism as protective factors against depression.
Thinking styles: People engage in different types of thinking, some of which are helpful, while others are unhelpful and contribute to depression.
Physical illness and medication: Sometimes the symptoms of a physical illness (e.g. neurological or hormonal illness) will resemble, or include the symptoms of depression. Also, some medications used to treat certain conditions may result in depression as a side effect (e.g. the effect of certain drugs used to treat high blood pressure). Depression may also develop, as a secondary consequence, in people who are physically unwell, particularly with long-standing (chronic) conditions where pain or disability is prominent. It can be difficult to decide which symptoms (such as weight loss or tiredness or sleep disturbance) are related to the illness and which have developed as a consequence of depression.
Alcohol and other drugs: Various drugs, including alcohol, interfere with the normal balance of brain chemicals and influence behaviour which can lead to symptoms of depression. A person with an alcohol problem is five times more likely to develop depression compared to the general population. Chronic intoxication is associated with substantial increase in the frequency and severity of depression and also increases the risk of suicide.
Stressful life events: Many people begin to experience anxiety after a stressful life event such as a relationship breakdown, loss of a job, being diagnosed with a serious illness, death of a loved one, or a combination of stressful events.
Childhood experiences: People who have experienced traumatic events early in life, such as bullying or childhood abuse (physical, emotional or sexual abuse), may be vulnerable to depression as a consequence. The outcome of such abuse depends on a number of factors including the nature, severity and duration of the abuse, as well as the child's other vulnerabilities and strengths, and the availability of effective supports.

How might depression change over time?

According to the American Psychiatric Association (2000):

symptoms of depression usually develop over a few days to weeks;
if a depressive episode is untreated, it usually lasts for at least 4 months or longer;
people can have isolated episodes of depression that are separated by many years without any depressive symptoms, whereas others have clusters of episodes and still others have increasingly frequent episodes as they grow older;
the more episodes of depression, the more likely a person is to develop a subsequent episode: 60% of people with a single episode of depression are likely to develop another episode; people with two episodes of depression have a 70% chance of developing a third episode and those who have had three episodes of depression have a 90% chance of experiencing a fourth episode;
with treatment, 60% of people experiencing a depressive episode can expect to be symptom free;
in about 20-30% of cases of a depressive episode, some mild symptoms continue to persist for months to years without meeting the full criteria for depression. In such cases, another episode of depression is more likely than for those who are symptom free after an episode;
in about 5-10% of episodes, the symptoms can continue for two or more years and meet the criteria for chronic depression.

What effect can depression have on a person’s life?

Depression can have a significant impact on a person’s quality of life. It can interfere with interpersonal relationships, family life, work, and social activities.

The following diagram depicts the cycle experienced by people with depression (Burns, 1980):

Treatment of depression

The precise treatment for depression will differ for each person, and will also differ depending on the type of depression and the mental health professionals providing treatment (e.g. general practitioners, psychiatrists, psychologists, social workers or counsellors). Such professionals often work in teams to provide integrated and comprehensive treatment approaches.

The treatments for depression that have been scientifically established as being effective include:

Antidepressant medication

Antidepressant medication is an essential component of treatment for moderate to severe depression and may be necessary when depression is considered mild but chronic (i.e. longer term). There are a number of antidepressant medications available and the amount and type taken varies from person to person. To provide a simplified description, antidepressants are broadly classified according to their mode of action on neurotransmitters in the brain and include:

Selective Serotonin-Reuptake Inhibitors (SSRIs): SSRIs (e.g. citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline) are the first choice of treatments for people with mild to moderate depression or if antidepressant medication is required during pregnancy or when breastfeeding.
Selective Serotonin/Noradrenaline-Reuptake Inhibitor (SNRI): At lower doses, SNRIs (e.g. venlafaxine) are similar in their therapeutic effects to SSRIs. However, at medium to higher doses (i.e. 225-300g), they are particularly useful for more severe depression and where treatment with other antidepressants has not been effective (Kennedy, Lam, Nutt & Thase, 2004).
Tricylic Antidepressants (TCAs): TCAs (e.g. amitriptyline, clomipramine, imipramine, nortriptyline, doxepin, dothiepin, trimipramine) are the treatment of choice for more severe depression and depression that is not responsive to SSRIs. However, with newer treatments available with less adverse side effects, TCAs tend not to be used for mild to moderate depression.
Noradrenaline reuptake inhibitor (NRI): Reboxetine (and more recently Cymbalta) are NRIs that have proved to be effective when used in combination with SSRIs in the treatment of major depression that has not responded to other antidepressant medications (Fava, 2000).
Noradrenaline and selective serotonin antagonist (NaSSA): NaSSAs (e.g. mirtazapine and mianserin) have been found to be useful in the treatment of depression associated with anxiety or insomnia, and has been useful for depression where treatment with other medications has failed and where other medications are not well tolerated due to side effects, especially sexual dysfunction.
Monoamine Oxidase Inhibitors (MAOIs): MAOIs (e.g. phenelzine and tranylcypromine) were one of the first classes of antidepressants discovered. They, however, are now mainly used when other antidepressants have been found not to be effective (Kennedy et al., 2004). MAOIs increase energy and initiative and therefore, stopping MAOIs may be difficult because patients complain of tiredness and apathy. Certain foods and drugs need to be avoided when using MAOI’s and it is, therefore, important to discuss your diet, as well as over the counter medications with your doctor.
Reversible Inhibitors of Monoamine Oxidase (RIMAs): Moclobemide is a RIMA that is primarily used in the treatment of mild to moderate depression and where short-term treatment is anticipated. It can also be useful in the withdrawal phase of coming off irreversible MAOIs.

More information about specific medications and dosage can be obtained from your doctor or pharmacist.

Each class of antidepressant medication also has different side effects and these will be explained to you be your doctor. If you notice any side effects ensure to discuss them with your doctor.

Psychological therapies

Psychological therapies that have received scientific support for treatment of depression include cognitive behavioural therapy (CBT) and interpersonal therapy (IPT).

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) helps reduce distressing emotions, symptoms and life-problems by considering the way a person thinks, feels, and behaves.

CBT is:

time limited (8-16 sessions);
collaborative, with the therapist and client working together; and
has a ‘here and now’ focus.

The main goals of CBT are to reduce distressing emotions and symptoms, so that life regains balance and quality of life is improved. CBT will also equip people with skills and strategies that reduce the chance of them re-experiencing difficulties. If difficulties do recur, the strategies learnt will help people to manage these so that these problems are experienced with less intensity, and resolved more quickly. CBT can help people to feel better about themselves and teach them skills to cope more easily and effectively with day-to-day situations and stresses.

CBT may be sufficient on its own, but can also be used as a second line of treatment in conjunction with other approaches such as medication (e.g. in the case of severe or chronic depression).

Interpersonal therapy

Interpersonal Therapy (IPT) is a treatment approach which recognises that difficulties with people can contribute to feelings of depression. This kind of therapy also emphasises that good relationships with others are important and can provide buffers against painful emotions.

IPT also has a ‘here and now’ focus to help people resolve some of the current problems in their interpersonal relationships. It is a therapy that assists in the improvement of interpersonal relationships by strengthening communication skills and self-esteem.

IPT is time limited, with treatment often lasting 6 to 12 sessions. Like other psychological therapies, the main goal of IPT is to reduce distressing emotions and symptoms in order to improve quality of life. IPT aims to reduce difficulties in interpersonal relationships, and to build new skills that can help foster positive and useful communication with others. Relationships are seen as the vehicle for change, which in turn can produce improvements in other areas such as mood and motivation.

Electro-convulsive therapy

Electro-convulsive therapy (ECT), or shock therapy as it has been called, is the most effective method of treatment for people with:

severe forms of depression, including depression that has not lifted despite intensive treatments with other forms of therapy;
major depression with psychotic features, especially with delusions (e.g., fixed, false beliefs such as the overwhelming belief that one is rotting away; that one is being punished for some past act);
major depression with melancholic features (e.g. retardation and slowing).

ECT is one of the fastest treatments available for severe depression. A depressed person generally receives at least six treatments of this type, given every second day.

Common side effects of ECT include:

Headaches, drowsiness and nausea often occur immediately after ECT, but are usually short-lasting and harmless. These are mainly anaesthetic after-effects rather than side effects of the ECT.
Memory loss, for things learned before and/or after the ECT. Both types of memory loss usually resolve within a few months (for up to six months) following completion of the ECT

Complementary and natural therapies

Complementary and natural therapies (e.g. herbal medicines, acupuncture, and hypnotherapy) are often used by individuals undergoing conventional treatment for psychiatric symptoms. In the treatment of depression, exercise, St John’s Wort and SAM-e, have received some scientific support. Furthermore, light therapy has received support for major depression with seasonal pattern.

Exercise

An exercise program can help in significantly reducing the symptoms of depression (Manger & Motta, 2005). Furthermore, exercise may also help to deal with some of the side effects of antidepressant medication, such as managing weight gain, reducing anxiety and improving sleep. It is important to choose a regular exercise that you find enjoyable because you are more likely to continue with your exercise plan if you enjoy it.

St John's Wort

St John's Wort is commonly used as an antidepressant for mild to moderate depression. Given that St John’s Wort is a natural medicine, the strength or dose is not controlled and therefore can vary. There seem to be fewer adverse effects with St John's Wort than with conventional antidepressants. However, recent findings suggest that St John's Wort interferes significantly with hepatic (liver) and renal (kidney) clearance of many other pharmacological agents, thus resulting in elevations in the blood levels of these other substances. This is a potentially dangerous situation in people who have to take other drugs and requires careful monitoring by an informed health professional or doctor. The long-term use and efficacy of St John's Wort in severe depression has not yet been determined. It is important to inform your doctor of any and every medication (prescription and over the counter) you are taking.

SAM-e

S-adenosyl-methionine (SAM-e for short), is a chemical that occurs naturally in all cells of the body. To date, several studies have indicated that SAM-e is effective in treating mild to moderate depression (Bressa, 1994; Kagan, Sultzer, Rosenlicht, & Gerner, 1990). Furthermore, it is suggested that SAM-e has very few side effects, but may actually trigger an episode of mania for people with bipolar disorder. It is also recommended that people who are taking other medications (e.g. prescribed antidepressants) consult with their doctor before commencing SAM-e.

Light therapy

Light therapy is the controlled use of artificial light primarily applied in the treatment of major depression with seasonal pattern, often referred to as Seasonal Affective Disorder (SADS) or winter depression. In general, light therapy is a well-tolerated, safe procedure. Although mild side effects, such as eyestrain, headache, insomnia, nausea and fatigue are common, it is rare for the side effects to be severe enough to interrupt or halt a course of treatment. SADS is quite uncommon in Australia; it is more of an issue in the Northern Hemisphere.

How long will treatment last for?

The length of treatment of depression will vary depending on the number of previous episodes of depression and the severity of the symptoms. The more episodes experienced and the more severe the symptoms, the longer treatment will be required. Furthermore, different combination of treatments may be required to alleviate symptoms. People who have experienced a number of episodes or have severe, chronic depression may be suggested to take medication indefinitely and to consult a mental health professional for regular monitoring.

Expectations for the future

As stated previously, some people will experience only one episode of depression in their lifetime while others will have recurrent episodes. For those with recurrent episodes, some will be symptom free between episodes, while others will have mild symptoms.

Progress through treatment is also likely to have its ups and downs. For example, a person recovering from an episode of depression may have a ‘bad’ day, where they feel down. However, by implementing the strategies they have learnt in CBT/IPT and continuing to take their medication as prescribed, they are likely to continue progressing towards recovery. It can also be helpful to have ‘booster sessions’ with a doctor or mental health professional to help get back on track.

What can I do to help myself?

If you experience symptoms of depression, consult your doctor, clinical psychologist or mental health professional in order to be appropriately assessed and for suitable treatment to be administered. Please refer to the end of this brochure for contact details of relevant professionals at Sentiens.
Follow the treatment as prescribed and if you are unsure about your treatment or its side effects, please ask your doctor or mental health professional.

References

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Depression