Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings, and sense of well-being. People with a depressed mood may be notably sad, anxious, or empty; they may also feel notably hopeless, helpless, dejected, or worthless. Other symptoms expressed may include senses of guilt, irritability, or anger. Further feelings expressed by these individuals may include feeling ashamed or an expressed restlessness. These individuals may notably lose interest in activities that they once considered pleasurable to family and friends or otherwise experience either a loss of appetite or overeating. Experiencing problems concentrating, remembering general facts or details, otherwise making decisions or experiencing relationship difficulties may also be notable factors in these individuals' depression and may also lead to their attempting or actually committing suicide.
In addition to all the aforementioned factors, actions committed by siblings of these individuals may also contribute to the decision-making in individuals experiencing depression or attempting to take their own lives.
Expressed insomnia, excessive sleeping, fatigue, and vocalizing general aches, pains, and digestive problems and a reduced energy may also be present in individuals experiencing depression.
A depressed mood is a feature of some psychiatric syndromes such as major depressive disorder and dysthymia, but it may also be a normal temporary reaction to life events such as bereavement, a symptom of some bodily ailments or a side effect of some drugs and medical treatments. A Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis distinguishes an episode (or 'state') of depression from the habitual (or 'trait') depressive symptoms someone can experience as part of their personality.
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Causes
Life events
Adversity in childhood, such as bereavement, neglect, mental abuse, physical abuse, sexual abuse, and unequal parental treatment of siblings can contribute to depression in adulthood. Childhood physical or sexual abuse in particular significantly correlates with the likelihood of experiencing depression over the life course.
Life events and changes that may precipitate depressed mood include childbirth, menopause, financial difficulties, unemployment, work stress, a medical diagnosis (cancer, HIV, etc.), bullying, loss of a loved one, natural disasters, social isolation, rape, relationship troubles, jealousy, separation, and catastrophic injury. Adolescents may be especially prone to experiencing depressed mood following social rejection, peer pressure and bullying.
Personality
High scores on the personality domain neuroticism make the development of depressive symptoms as well as all kinds of depression diagnoses more likely, and depression is associated with low extraversion.
Medical treatments
Depression may also be iatrogenic (the result of healthcare), such as drug induced depression. Therapies associated with depression include interferon therapy, beta-blockers, Isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics, and hormonal agents such as gonadotropin-releasing hormone agonist.
Substance-induced
Several drugs of abuse can cause or exacerbate depression, whether in intoxication, withdrawal, and from chronic use. These include alcohol, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs such as heroin), stimulants (such as cocaine and amphetamines), hallucinogens, and inhalants.
Non-psychiatric illnesses
Depressed mood can be the result of a number of infectious diseases, nutritional deficiencies, neurological conditions and physiological problems, including hypoandrogenism (in men), Addison's disease, Cushing's syndrome, hypothyroidism, Lyme disease, multiple sclerosis, Parkinson's disease, chronic pain, stroke, diabetes, and cancer.
Psychiatric syndromes
A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition and energy levels, but may also involve one or more episodes of depression. When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder. Outside the mood disorders: borderline personality disorder often features an extremely intense depressive mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode; and posttraumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly accompanied by depressed mood. Depression is sometimes associated with substance use disorder. Both legal and illegal drugs can cause substance use disorder.
Historical legacy
Researchers have begun to conceptualize ways in which the historical legacies of racism and colonialism may create depressive conditions.
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Assessment
Questionnaires and checklists such as the Beck Depression Inventory or the Children's Depression Inventory can be used by a mental health provider to help detect, and assess the severity of depression. The Seasonal Pattern Assessment Questionnaire can be used to screen for seasonal affective disorder. Semi structured interviews such as the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) and the Structured Clinical Interview for DSM-IV (SCID) are used for diagnostic confirmation of depression.
Treatment
Depressed mood may not require professional treatment, and may be a normal temporary reaction to life events, a symptom of some medical condition, or a side effect of some drugs or medical treatments. A prolonged depressed mood, especially in combination with other symptoms, may lead to a diagnosis of a psychiatric or medical condition which may benefit from treatment. Different sub-divisions of depression have different treatment approaches. In the United States, it has been estimated that two thirds of people with depression do not actively seek treatment. The World Health Organisation (WHO) has predicted that by 2030, depression will account for the highest level of disability accorded any physical or mental disorder in the world (WHO, 2008).
The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. A recent meta-analysis also indicated that most antidepressants, besides fluoxetine, do not seem to offer a clear advantage for children and adolescents in the acute treatment of major depressive disorder.
Epidemiology
About a quarter of medical students have depressive symptoms.
Racial issue
African Americans
Research has shown that African Americans define, express, and experience depression in distinct ways. African Americans have described depression as feeling "stuck", "down", "unable to move", and hopeless. In Sirry Alang's 12-month study of a predominantly Black neighborhood in the Midwestern US, African Americans reported that individuals in their community, including themselves, expressed depression through anger, aggression, and excessive socialization with friends and family in order to deny or hide feelings of depression. In addition, African Americans report somatic symptoms, such as pain or numbness throughout the body. A 2003 study of individuals seeking psychotherapy found that in comparison to Caucasian Americans, African Americans experience more insomnia, decreased sex drive, and decreased appetite as the severity of their depression increases. Researchers note that these expressions of depression differ from the commonly used DSM-V criteria used to diagnose individuals with major depressive disorder.
Studies show that African Americans see depression as a sign of weakness. In particular, African American men deny and suppress depressive symptoms due to the stigma of mental health problems and cultural expectations that men should hide their emotions. Parents may not acknowledge their children's depression because they mistake the symptoms for something else, they doubt treatment will help, and/or they fear being at fault for their children's depression.
Research has shown a correlation between depression and financial hardships in African American communities. Interpersonal conflicts, such as family issues, are also commonly cited causes of depression. In a study in New York, ministers of predominantly African American churches attributed depression to the stress of institutional racism and other stressors related to being African American in the US.
For African American adolescents, maternal support has been shown to be a protective factor against depression. Some studies suggest that employment, non-sport extracurricular activities, familism, predominantly minority schools, inductive parenting, social activities, and teacher relationships protect against depression. Religiosity has not been shown to protect against depression for African American adolescents. However, research suggests that African American adults tend to seek support from ministers or priests and that church-based depression services may be a feasible way to support individuals with depression.
Asian Americans
There is inconsistent data about the prevalence of depression among Asian Americans. Several studies suggest that Asian Americans experience depression at higher rates compared to other ethnic groups, while others posit that the rates are lower or comparable to other groups. The true prevalence of depression is difficult to measure because of the lack of comprehensive studies and the large variety of ethnic groups within the Asian American population. Overall, Asian Americans underutilize mental health services. Asian Americans may not seek mental health services due to the lack of culturally competent mental health professionals. In addition, the desire to "save face" to avoid bring shame on one's family or self may prevent Asian Americans from getting help.
Asian Americans who experience depression commonly report physical or somatic symptoms such as appetite changes, headaches, sleep problems, and fatigue. Although research tends to emphasize how Asian Americans report bodily complaints, Asian Americans also report experiencing depressive moods and feelings, such as sadness.
It is important to note that commonly used tools to diagnose depression in the US may not be able to detect depression in Asian Americans, due to differences in the ways depression may be expressed. For example, in Western cultures, depression may be defined as feeling helpless. In contrast, Eastern Asian cultures that value "selfless subordination" may not associate helplessness with depression.
In the Asian American Literary Review's DSM: Asian American Edition, Aileen Alfonso Duldulao, an epidemiologist who has been diagnosed with major depressive disorder along with other mental health disorders says, "Yet I would have never characterized what I have experienced using DSM-V derived symptomatic descriptions or ICD-10 diagnostic criteria. I've experienced highs and lows, and marveled at the depth of my own sadness from what seems like afar. I've cried incessantly for losses so deep that a language of loss no longer exists."
Asian culture may influence how individuals define depression. For example, Vietnamese Americans may experience some depressive symptoms that cannot be translated into English. Similarly, a study of Asian Indian Americans suggests that that older Asians who only speak one language are more likely to present depression in ways that match how it is expressed in their homeland. In Chinese culture, shenjing shuairo, or neurasthenia, is defined as a weakness of the nerves and mental and/or physical fatigue. Culture-bound syndromes such as shenjing shuairo have been shown to have some overlap with definitions of depression in the DSM and ICD, which are commonly used to detect depression. Researchers have found that 40% to 90% of patients diagnosed with neurasthenia met the criteria for depression and showed improvement after taking antidepressant medications.
Researchers have found that depressed Asian Americans are more likely to report having negative relationships with family members and being unable to talk to family members about their problems or worries. In particular, Asian American high school students dealing with depression report that their parents do not show much interest their feelings and ideas. Several studies have also shown that depressed Asian American adolescents and young adults tend to experience conflicts with their immigrant parents, arising from differences in how they adapt to culture in the US. Family disharmony may occur when Asian American children integrate into the mainstream culture, while their parents hold onto their own ethnic culture, values, and language.
Asian Americans experiencing depression may feel like they are not accepted in the US. In a study of Asian Americans with major depression, 21% reported experiencing high levels of racial discrimination and 43% reported moderate levels of racial discrimination. Furthermore, Asian American adolescents who identify more with their ethnic culture and less with American culture have higher levels of depression than adolescents who identify more with American culture. However, a different study shows that depressed Asian Americans who are integrated in American culture may feel like outsiders in both the Asian community and Asian American community because they feel like they cannot fully identify with either culture. On the other hand, parents experiencing depression are more likely to feel separated from the Asian American and Anglo communities. These different findings may point to how Asian Americans' depression is linked to their sense of belonging in groups overall.
There are some culturally specific resources for Asian Americans dealing with depression. The Asian LifeNet Hotline, which can be reached at 1-877-990-8585, is a 24-hour hotline with crisis counselors who can speak different over 140 languages including Cantonese, Mandarin, Japanese, Korean, and Fujianese. In Boston, the Asian Women's Action for Resilience and Empowerment (AWARE) project provides culturally sensitive group psychotherapy for Asian American women. The group helps participants learn how to cope with depression and recognize that they are not alone.
Sex differences
Women experience a higher rate of major depression than men. While women are much more likely to express somatic symptoms of both distress and depression than men, such as loss of or an increase in appetite, sleep disturbances and fatigue accompanied by pain and anxiety, the gender difference expressed is much smaller in other aspects of depression. Instances of suicide in men is much greater than in women. In a report by Lund University in Sweden and Stanford University, it was shown that men commit suicide at a rate almost three times that of women in Sweden, and the Centers for Disease Control and Prevention and National Center for Injury Prevention and Control report that the rate in the US is almost four times as many males as females. However, women have higher rates of suicide ideation and attempts. The difference is attributed to men choosing more effective methods resulting in the higher rate of success. This research would suggest that women are more likely to discuss their depression issues, whereas men are more likely to try and hide them. The culture of women being more free to express psychological and emotional feelings than men could also be a contributing factor to this phenomenon.
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