Explains depression, including possible causes and how you can access treatment and support. Includes tips for helping yourself, and guidance for friends and family.
What is depression?
We often use the expression ‘I feel depressed’ when we’re feeling sad or miserable about life. Usually, these feelings pass in due course. But, if the feelings are interfering with your life and don’t go away after a couple of weeks, or if they come back, over and over again, for a few days at a time, it could be a sign that you’re depressed in the medical sense of the term.
In its mildest form, depression can mean just being in low spirits. It doesn’t stop you leading your normal life, but makes everything harder to do and seem less worthwhile. At its most severe, major depression (clinical depression) can be life-threatening, because it can make you feel suicidal or simply give up the will to live.
There are also some specific forms of depression:
- Seasonal affective disorder (SAD) – this is seasonal depression which is related to day length. It usually comes on in the autumn and winter, when days are short and the sun is low in the sky, and gets better as the days get longer and brighter.
- Postnatal depression – many mothers have ‘the baby blues’ soon after the birth of their baby, but it usually passes after a day or two. Postnatal depression is a much more serious problem and can occur any time between two weeks and two years after the birth.
- Bipolar disorder (manic depression) – some people have major mood swings, when periods of depression alternate with periods of mania. When manic, they are in a state of high excitement, and may plan and may try to carry out over-ambitious schemes and ideas. They often then have periods of severe depression.
What are the symptoms of depression?
Am I depressed?
The following are all symptoms of depression, and if you tick off five or more of any of them you are probably depressed.
- I am low-spirited for much of the time, every day
- I feel restless and agitated
- I get tearful easily
- I feel numb, empty and full of despair
- I feel isolated and unable to relate to other people
- I am unusually irritable or impatient
- I find no pleasure in life or things I usually enjoy
- I feel helpless
- I have lost interest in sex
- I am experiencing a sense of unreality
- I’m not doing activities I usually enjoy
- I am avoiding social events I usually enjoy
- I have cut myself off from others and can’t ask for help
- I am self-harming
- I find it difficult to speak
- I am having difficulty remembering things
- I find it hard to concentrate or make decisions
- I blame myself a lot and feel guilty about things
- I have no self-confidence or self-esteem
- I am having a lot of negative thoughts
- The future seems bleak
- What’s the point?
- I have been thinking about suicide
My physical symptoms
- I have difficulty sleeping
- I am sleeping much more than usual
- I feel tired and have no energy
- I have lost my appetite, and am losing weight
- I am eating a lot more than usual and putting on weight
- I have physical aches and pains with no obvious physical cause
- I am moving very slowly
- I am using more tobacco, alcohol or other drugs than usual
Depression presents itself in many different ways. You may not realise what’s going on, because sometimes your problems seem to be physical, rather than mental or emotional. There are also some other mental health problems often linked to depression.
People who are depressed often have anxiety as well – the two problems often occur together, and each can make the other worse. If you are feeling anxious, your mind may be full of busy, repetitive thoughts, which make it hard to concentrate, relax, or sleep. You may have physical symptoms, such as headaches, aching muscles, sweating and dizziness.
Anxiety may cause physical exhaustion and general ill health.
It was like I’d fallen into a deep abyss… Even when I tried scrambling up the sides, it was no good, as exhaustion and an overwhelming feeling of nothingness pulled me back down again. I felt like I’d never see the light again…
If you are severely depressed you may start to have experiences or thoughts that others around you do not share. For example, you may hear voices, see visions, believe that you are evil, or are influencing events in a way that is harmful to others. You may believe that you are a bad person and you deserve to feel as you do. These are false beliefs and may be part of the depression.
You may feel that life is not worth living and start thinking about ways of killing yourself. Thoughts like these may seem difficult to control and be very frightening. If you feel that you may harm yourself talk to someone immediately.
Depression is like Hell on Earth, it’s dark, lonely and very selfish. The feeling of not wanting to live (but not wanting to die)… I can’t get going and feel like I can’t do anything… One thing about suffering from depression is that it’s made me a better, stronger person.
What causes depression?
Depression varies very much from person to person and can happen for one or more reasons. Occasionally it may appear for no obvious reason.
In many cases, the first time someone becomes depressed, it has been triggered by an unwelcome or traumatic event, such as being sacked, divorced, or physically or sexually assaulted.
Often events or experiences that trigger depression can also be seen as a loss of some kind. It could be following the actual death of someone close, a major life change (such as moving house or changing jobs), or simply moving from one phase of life into another, e.g. as you reach retirement, children leave home, or you come to realise that you may never have a family of your own.
It’s not just the negative experience that causes the depression, but how we deal with it. If the feelings provoked are not expressed or explored at the time, they fester and contribute towards depression.
In some cases some people call depression ‘frozen anger’. You may have experienced something which left you feeling angry and helpless, and if you were unable to express your feelings at the time – perhaps because you were a child, or your feelings were unacceptable to others – the anger becomes internalised and is expressed as depression.
If you experienced a traumatic event in childhood, or were abused physically or emotionally, or were not helped to learn good coping skills as you grew up, this can leave you less able to cope with difficulties as an adult.
The following conditions may cause depression, but are sometimes overlooked because of the focus on their physical symptoms:
- conditions affecting the brain and nervous system
- hormonal problems, especially thyroid and parathyroid problems
- symptoms relating to the menstrual cycle or the menopause
- low blood sugar
- sleep problems.
If you think any of the above conditions apply to you, make sure your doctor knows about them. Some of these problems can be diagnosed by simple blood tests, and your doctor may suggest that these are done to help make the right diagnosis, or you can ask for blood tests if you think they might be relevant for you.
Side effects of medication
Depression is a side effect of a lot of different medicines; for example, many people become depressed after a heart attack, and this may be more likely if they are taking beta blocker medicines as part of their treatment.
If you are feeling depressed after starting any kind of medication, it’s worth looking at the patient information leaflet that came with the drug to see if depression is listed among the side effects. If you think a drug is causing your depression, you could mention this to your doctor and see if there is an alternative you could take, especially if you are expecting the treatment to last some time.
Poor diet and general lack of fitness can both contribute to depression. In addition, anecdotal evidence suggests that occasionally people become very depressed in response to some specific foods. Such a reaction is very individual, and people are often not aware of the particular food substance or drink that is causing the problem. But if you suddenly feel depressed for no apparent reason, it may be worth considering whether you have eaten or drunk something new, and whether this might have caused your sudden change of mood. If this is the cause, your mood should lift very quickly, so long as you don’t consume any more of the particular item.
Street drugs and alcohol
Although you may be very tempted to have a drink to cheer you up, alcohol is a depressant, and will tend to make you feel worse overall. Some street drugs can also make you depressed, especially if used repeatedly.
Although no specific genes for depression, have been identified, it does seem to run in families to some extent, and some of us are more prone to depression than others. This could also be because we learn behaviour and ways of responding from our relatives, as well as inheriting our genes from them.
Chemical changes in the brain
Because antidepressants work by changing brain chemistry, many people have assumed that depression must be caused by changes in brain chemistry that are then ‘corrected’ by the drugs. Some doctors may tell you that you have a ‘chemical imbalance’ and need medication to correct it. But the evidence for this, apart from the effects of medication, is very weak, and if changes to brain chemistry occur, we don’t know whether these are the result of the depression or its cause. Although there are physical tests which are occasionally used in research on depression, they are not very accurate or consistent, and there are none that are done routinely to help make a diagnosis.
What can I do to help myself?
An important thing to accept is that there are usually no instant solutions to problems in life. Solving problems involves time, energy and work. When you are feeling depressed, you may not be feeling energetic or motivated to work. But if you are able to take an active part in your treatment, it should help your situation.
Break the cycle of negativity
If you are starting to feel depressed it can be very easy to get into a cycle of automatic negative thoughts that then become difficult for you to challenge: you get depressed and then you get more depressed about being depressed. Being in a state of depression can then become a bigger problem than the actual difficulties that caused it in the first place.
You need to make a conscious effort to break the hold that the depression has on you. Deciding to do something to help yourself is the most important step you can take.
Try to recognise the pattern of negative thinking when you are doing it, and replace it with a more constructive activity. Look for things to do that occupy your mind.
Research and individual personal experience show that regular exercise can be very effective in lifting your mood and increasing your energy levels, and it is also likely to improve your appetite and sleep. Physical activity stimulates chemicals in the brain called endorphins, which can help you to feel better.
Although you may not feel like it to start with, it’s very therapeutic to take part in physical activities, for 20 minutes a day. It does not have to be very strenuous or sporty to be effective. Walking at a reasonable speed and taking notice of what is around you is a good start. Walking in a green environment, such as the park or the countryside, is especially helpful.
If you like gardening but haven’t got a garden, you might find there is a community garden near you which you could help with.
You may also enjoy swimming, running, or joining in competitive or team sports, which can also give you the opportunity for social contact with people who share your interests.
It’s so important to keep as busy as your depression allows you to. It’s easy to dismiss engaging in hobbies and activities, saying that they wont help and giving up… even people who don’t have depression become low if they are bored or under-stimulated for long periods. Learning to become active again played an essential part in my recovery and helps me to stay well.
Connect with other people
Although you many not feel like it, keeping in touch with people can help you feel a bit more grounded and sometimes get things more in perspective. Try a short phone call to a close friend or relative, or if you can’t manage it, just an email or text message.
When you feel ready, you may find it helpful to do something to help other people, as this may help overcome any feelings of isolation you have, take your mind off your own problems and make you feel better about yourself.
It can also be a great relief to meet and share experiences with other people who are going through the same thing you are.
Self-help groups can show you how other people have coped and provide mutual support, as well as breaking down feelings of isolation. They are often led by people who have overcome depression themselves.
Care for yourself
You need to do things that will improve the way you feel about yourself.
- Allow yourself positive experiences and treats that reinforce the idea that you deserve good things. eg a long bath, a day out with a friend.
- Pay attention to your personal appearance.
- Set yourself goals that you can achieve and that will give you a sense of satisfaction.
- If you find it hard to remember things, you may want to write them down on sticky notes, in a diary or set reminders on your mobile phone.
- Look after yourself by eating healthily, as much as possible. Oily fish, in particular, may help reduce depression.
- Be cautious with tobacco, alcohol or other drugs, which make depression worse, and a lot of caffeine which may make you a bit jittery.
Would I change what happened to me? Definitely not. It made me who I am, its part of me and it’s made me a better person…
I started enjoying life again. I could look to the future and want to live it… Believe me, it can get better.
What treatments are available?
At a time when you may find making decisions difficult, it can also seem like an added burden to try and choose between a range of treatment options.
The National Institute for Health and Care Excellence (NICE) guidelines on the treatment of depression recommend:
- active monitoring – this is for mild depression and means keeping an eye on you while waiting to see if your depression goes away without treatment, which mild depression often does
- cognitive behaviour therapy (CBT), including self-help books, computerised CBT for mild depression; a series of sessions with a therapist for more severe depression
- mindfulness-based cognitive therapy
- behavioural activation
- other forms of talking treatment, such as counselling or interpersonal psychotherapy.
- medication for severe depression, but not for mild to moderate depression unless other treatments have not helped. This should be combined with CBT or psychotherapy
The Improving Access to Psychological Therapies (IAPT) programme, aims to make talking (psychological) treatments that follow NICE guidance available to everyone who needs them, regardless of race, age, gender, or where they live. A talking treatment should be available to you via your GP. The choice will depend on what’s available locally, your own preferences, how severe your depression is and other factors.
- Cognitive behaviour therapy (CBT) helps to identify and change negative thoughts and feelings affecting your behaviour and, although often a short-term treatment, may last up to 12 months. For mild depression you may be offered computerised CBT, which uses a programme you can follow either by yourself or in addition to sessions with a therapist.
- Mindfulness-based cognitive therapy is an approach to wellbeing that involves accepting life, and living and paying attention to the present moment. It includes taking time to see what is happening around you in a non-judgmental way, rather than going over your problems again and again. Mindfulness-based cognitive therapy is usually done in groups.
Mindfulness (is) a neat little trick that really helps and I wish I’d been taught it years ago.
- Behavioural activation makes you look at the simple everyday tasks you may be avoiding and start doing them. Activity helps you to feel better, and once you have conquered some everyday tasks, you may feel ready to tackle some bigger ones. For example, you may have felt too depressed to do the washing up and let it pile up in the kitchen. The bigger the pile, the less you feel like doing it. Behavioural activation would encourage you to tackle it, even if you start by only doing some of it. As you do it, the dishes get clean, your kitchen gets tidier, and you feel a bit better about everything. Behavioural activation usually forms part of a CBT programme, but may be offered on its own.
- Guided self-help delivers a 6-8 week therapy programme through selfhelp books, under the guidance of a healthcare professional.
- Interpersonal psychotherapy focuses on relationships. Therapy can continue for 6 to 12 months.
- Counselling, which can be short- or long-term. This involves talking with someone who is trained to listen with empathy and acceptance. It allows you to express your feelings and helps you to find your own solutions to your problems.
- Psychodynamic counselling and psychotherapy focus on how past experiences may be contributing to experiences and feelings in the present. Therapy can be short- or long-term. It may be more frequent and intensive than counselling, and may go deeply into childhood experience and significant relationships. It may not be available on the NHS.
- Group therapy allows a group of people to work together on their problems, with a therapist. You may find it easier to talk with others who have similar experiences, and that the insights of others help you to understand yourself better; you may also learn about relationships with others.
Whatever progress I have made in my battle with depression, is due entirely to group psychotherapy. It has transformed my little life in ways I thought impossible to begin with, and shown me that whenever I have suddenly felt worse, there is ALWAYS an explanation from my past.
You can also seek therapy or counselling privately, if you are able to pay. For lists of qualified and regulated therapists, see ‘Useful contacts’. Some offer a reduced fee for people on a limited income.
Combining a psychological treatment with medication may be the most effective course for severe depression.
Antidepressant drugs work on brain chemicals (such as serotonin and noradrenaline) to lift your mood. It often takes between two to six weeks before the drugs take effect. They don’t cure depression, but they can make you feel better so that you may feel able to take action to deal with the problems causing your depression.
The NICE guidelines suggest that, for mild depression, antidepressants are not appropriate because the risk of side effects outweighs the chance of benefit, but they are recommended for severe depression, or moderate depression that has gone on for a long time.
If you do take antidepressants, the usual recommendation is that you stay on them for six months after you feel better in order to stop the depression coming back. Many people find them helpful, although they don’t work for everyone.
Antidepressants can cause unpleasant side effects, some of which are worse to begin with. Some can be dangerous when used with other drugs. Of the various types available, SSRIs (selective serotonin reuptake inhibitors, such as Cipramil or Prozac) are usually the preferred first choice because, they are usually better tolerated than some of the other antidepressants. But if these do not suit you for any reason, there are other types to try, which work in slightly different ways.
If you are having psychotic symptoms, your GP may refer you to a psychiatrist who may prescribe an antipsychotic drug, such as quetiapine (Seroquel).
Although exercise is something you can do for yourself, it is also recommended as a treatment for depression in the NICE guidelines, and some GPs will give you a prescription for exercise, referring you to a programme at a local gym or health centre.
Befriending, peer support and volunteering schemes
Your GP may put you in touch with a local befriending scheme, with trained volunteers who may visit you at home, or arrange to meet you somewhere for a chat, or a walk or other social occasion that you both enjoy.
You may be offered the help of a peer support worker. They have usually had similar experiences to you, and can empathise with your situation and offer hope for recovery, as well as helping you to access other services.
You might also be put in touch with a volunteering scheme where you can exchange skills or offer help to others who have problems that you might be able to help them with. For example, you might not feel up to cooking for yourself, but might feel able to cut someone’s grass for them. A neighbour might love cooking, but be unable to manage their garden. So you could exchange lawn-mowing for a hot meal, and both of you benefit.
Art and music therapies may help you to express how you are feeling, especially if you are having difficulty talking. Drama therapy may help you to come to terms with traumatic events that you may have experienced in the past and which may contribute to your depression. Writing about how you are feeling can also be very helpful, and there is no need to share this with anyone if you don’t want to. Arts therapies and writing groups may be available through a local group, such as a local Mind.
Alternative and complementary therapies
Practitioners of complementary and alternative medicine concern themselves with the person as a whole, and don’t just treat their symptoms. They spend more time with you than a GP can. Practitioners may offer treatments such as acupuncture, massage, homeopathy and herbal medicine that many people with depression have found helpful.
St John’s wort is one of the herbal remedies that many people find helpful, and may help to lift your mood. However, you should not take St John’s wort if you are taking prescription antidepressants. If you are taking any other medication you should seek advice from a pharmacist before adding St John’s wort, because it interferes with the effects of many other medicines.
What if my depression is worse, or won’t go away?
Your GP may refer you to a specialist mental health professional, such as a psychiatrist, psychologist or mental health nurse, who can review your treatment so far. They may suggest a different medication, or a combination of drugs with other treatments.
Social care and support
If you are very depressed, you may need support to live independently in the community. Your Community Health Team can provide support for you in your own home, and may include a psychiatrist, community psychiatric nurses (CPNs), social workers and peer support workers.
You may be allocated a named care coordinator and have a written treatment plan that specifies what your current treatment is, what should happen in an emergency or crisis, and any treatments you would prefer not to have.
Crisis resolution services
These are teams of doctors and nurses who provide intensive support, which will enable you to stay at home if you’re in crisis, rather than going into hospital.
If you are severely depressed, you may need to be cared for in hospital as an in-patient. This gives a psychiatrist the opportunity to monitor the effects of different treatments, and also means that you will get regular meals. Hospital can provide a safe and supportive environment if you are in a state of distress, and it may be comforting to have other people around you and to know that you are being cared for. However, it can be distressing to be on a ward where you may have little privacy, where you have to fit in to routines that may not suit you, and where you may be upset by the behaviour of other patients.
Generally, doctors prefer to keep patients out of hospital, but some patients are compulsorily detained, if it’s thought to be necessary for their own health or safety or the protection of others.
Electroconvulsive therapy (ECT)
This is a controversial treatment, and is usually suggested only if you are severely depressed and haven’t responded to talking treatments or different types of medication. ECT involves passing an electric current through the brain, while you are under general anaesthetic, in order to induce a convulsion, or fit, which is believed to lift the depression.
Some people find it very helpful, but it can also have severe side effects, including memory loss. You cannot be given ECT without your consent unless you are assessed as being incapable of giving consent.
Other physical treatments
For very severe depression that has not improved with any of the normal treatments, including ECT, there are other treatments including neurosurgery, and deep brain stimulation. These treatments are used extremely rarely.
What can friends or family do to help?
This section is for friends and family who want to support someone they know who has depression.
Feelings of hopelessness, helplessness and worthlessness are a major part of depression. This can mean someone avoids their friends and relatives, rather than asking for help or support. However, this is a time when they need your help and support most.
- Perhaps the most important thing that you can do is to encourage your friend or relative to seek appropriate treatment. You can reassure them that it is possible to do something to improve their situation, but you need to do so in a caring and sympathetic way.
- You can encourage them to talk about how they are feeling and get them to work out what they can do, or what they need to change, in order to deal with their depression.
- You can show that you care by listening, sympathetically, by being affectionate, by appreciating them, or simply by spending time with them.
- If they live alone and are keeping themselves isolated, you could leave a message so that they know you are concerned about them.
He used to have recurrent episodes and would shut himself away and not answer the door or the telephone, but if I wrote him a note, and managed to push it under the door, he would tell me later how much it meant to him. Sometimes it was enough to coax him out.
- Try not to blame the person for being depressed, or tell them to ‘pull themselves together’. They are probably already blaming themselves, and criticism is likely to make them feel even worse.
- Someone with depression may get irritable, and be more liable to misunderstand others, or feel misunderstood, than usual; they may need reassurance in some situations, and you may need to be patient with them.
- If your friend or relative has repeated episodes of depression you may be able to learn what their triggers are, or spot when an episode might be starting, and encourage them to take action before it gets any worse.
I find what helps is letting people who are understanding about your illness know when you’re having a bad day. My partner can tell me when one of my symptoms has started and reassure me.
- Remember that, even after someone has started treatment for depression, it still may be some time before they really start to feel better.
If your friend or relative is severely depressed, you may be faced with some hard decisions about how much to do on their behalf. If, for example, they are not looking after their physical needs, should you take over and do the shopping, cooking and cleaning for them, if you are able to? Or should you try and encourage them to do it? There are no easy answers to this situation. It will help if you can find someone who you can discuss these and other issues with and who may be able to share the responsibility with you.
Look after yourself
Supporting a friend or relative who is depressed can be an opportunity to build a closer and more satisfying relationship. However, it can also be hard work and frustrating, at times. Unless you pay attention to your own needs, it can make you feel depressed, too. There may be a local support group of others in your situation. You could also talk to your GP or another healthcare professional about getting help for yourself and your family.