Everyone experiences sadness or boredom at some point, especially after experiencing a disappointment like being refused a job position. These feelings of sadness, however, are usually short-lived and normal.

Depression, however, is a pathological condition characterized by intense feelings of long-lasting sadness and hopelessness and associated with other mental and physical changes. Depression can affect a person’s private, social and professional life.

It is estimated that 1 in 5 women and 1 in 10 men will experience depression at some point. Depression affects children and adolescents less commonly than adults. In Canada, nearly 3 million people suffer from severe depression at any time, but less than a third of them seek medical attention.

A typology of depression

There are several types of depression, and the diagnosis is mainly based on the nature and intensity of the psychological and physical symptoms, their duration, and their specific cause when they can be identified.

Clinical depression or major depressive disorder or MDD is the most important type of depression, in terms of prevalence and severity, but symptoms and their intensity vary widely among people. People with major depression do not necessarily have suicidal tendencies and may never have received medical treatment. The interest that these people have in many activities and the pleasure they derive from them, their energy level, their eating habits, and the phases of their sleep change.

Dysthymia refers to a mild to moderate state of depression that persists for at least 2 years, and often longer. Despite symptoms that are less severe than those of major depression, dysthymia can still affect a person’s quality of life. It is often ignored that dysthymia is a medical condition that responds equally favorably to the treatments indicated in the case of major depression. Over time, some people’s dysthymia at some point turns into major depression.

Bipolar disorder or manic-depressive illness is characterized by alternating periods of arousal with depressive episodes and a range of other prominent symptoms that do not appear in other types of depression.

Other types of depression include Seasonal Affective Disorder or SAD, psychotic depression, and postpartum depression.

• SAD which is a subtype of depression appears regularly at the same time each year (most often in the off-season or during winter in North America);
• Psychotic depression is characterized by a deep depressive state associated with hallucinations (the perception of phenomena that do not actually exist) or irrational beliefs (false ideas contrary to reason);
• Postpartum depression, which is a subtype of depression, often starts a few weeks after giving birth. It differs from the transient condition known as “third day syndrome” (or baby blues) which usually occurs 24 to 72 hours after childbirth. This transient condition is caused by hormonal changes that occur during pregnancy and after childbirth, and it usually resolves within 1 week or so. Postpartum depression lasts longer than the depressive state associated with “third day syndrome” and disrupts a woman’s emotional and social functioning.

In some cases, depression is associated with other chronic conditions that negatively affect the quality of life and well-being.

Causes of depression

There is no single cause for depression. Rather, it is usually the result of a combination of factors such as an imbalance of chemicals in the brain, family history, thoughts or beliefs, and significant events of a traumatic or stressful nature that increase the risk of depression.

The presence of too much or too little of the substances responsible for sending messages to the brain is also believed to be one of the contributing factors to depression. These chemicals also help regulate our emotions, behavior, and thoughts. How we see the world, and what happens to us, can also contribute to depression.

Depression has a genetic component (i.e., a family history). While the tendency to depression can be genetically inherited, the onset of depression can be caused by a number of factors.

Some of the triggers for depression are:

• significant painful or traumatic events (such as the loss of a loved one, a romantic break-up, a dismissal);
• medical conditions such as Parkinson’s disease, stroke, lupus, hypothyroidism, chronic pain, and some forms of cancer;
• the use of certain medications, including corticosteroids, anabolic steroids, narcotics, benzodiazepines, progesterone (found in some female hormonal pills) and illicit drugs such as amphetamines;
• alcohol, which has short-lived and possibly long-lasting depressive effects.
• It is essential to recognize that depression is not a condition that we can “recover” from on our own, and it is not because of personal weakness or the unwillingness to cope with the situation. .

Symptoms and Complications

Although we all feel sad at times, a diagnosis of clinical depression (major depression) is made when a person observes at least 5 of the symptoms listed below (one of them must be a depressed mood or a loss of interest or pleasure in daily activities) most of the time for at least 2 weeks:

• a depressed mood (sadness);
• loss of interest or pleasure in daily activities;
• changes in appetite or changes in body weight;
• tiredness or lack of energy;
• insomnia (difficulty sleeping) or chronic excess sleep;
• noticeable changes in activity level (anxious restlessness or slow reflexes);
• a feeling of self-worth or guilt;
• difficulty concentrating or making decisions;
• recurring thoughts of death or suicide.

Other symptoms of depression may appear, including:

• loss of interest in work and other activities;
• a withdrawal into oneself which consists of avoiding family members and friends;
• irritability;
• a tendency to cry easily;
• hallucinations (the perception of phenomena that do not actually exist);
• irrational beliefs
• muscle and body pain, such as headache, joint pain, or abdominal pain (some people have these symptoms rather than feeling sad).

Clinical depression can be of varying severity. In its extreme forms (eg with suicidal thoughts) it can be life threatening and therefore requires immediate medical attention.

Symptoms of other forms of depression, while generally milder, can still have negative effects on a person’s daily activities and quality of life.

People at risk

No one is safe from depression. But the following people would be slightly more at risk.

• People with a family or personal history of depression.
• People who are taking certain medications, such as psychostimulants, steroids, corticosteroids, anabolics, anticonvulsants, or the birth control pill. This is because the progestins in the birth control pill can affect mood. If so, discuss it with your doctor.

From a sociological perspective, the following groups are more affected by depression:

• Women: about twice as many women as men will experience depression at least once in their lifetime, although some marginal studies have sometimes found an equivalent frequency in both sexes. Women are more likely than men to see a doctor when they have symptoms of depression, which may partly explain why they are more often diagnosed with the disease. The hormonal system of women, more likely to influence the chemistry of the brain; thus, menopause can be associated with the onset of depression;
• people living in poverty and victims of domestic violence.
• Men living alone 90.
• Young people: The first depression often occurs in late adolescence or early adulthood. Suicide is the second leading cause of death among young people, after road accidents.
• Old people. Between 15% and 20% of the elderly experience periods of depression. They often go unnoticed.

Among the possible causes:

• loneliness;
• the death of a spouse or friends;
• physiological factors associated with aging, such as a significant drop in serotonin as well as other metabolic changes;
• undernourishment, which can cause nutritional deficiencies contributing to depression (especially folic acid and vitamin B12).
• Homosexuality. Several data, including a large cohort study in New Zealand, indicate that gays, lesbians and bisexuals are at higher risk for mental health problems, and more specifically for depression, anxiety disorders and suicidal behavior.
• People with chronic illness. Having chronic pain (migraine or back pain, for example) or a disabling illness (diabetes, stroke, etc.) greatly increases the risk of depression, especially in young people.

Diagnostic

To diagnose depression, your doctor will ask you questions about the symptoms you are experiencing and their severity. Your doctor will likely perform a physical exam and order blood tests to make sure that an underlying condition is not responsible for your symptoms.

Doctors are trained to help, take depression very seriously, and have the skills to treat it. You and your doctor can start by identifying the nature of the problem and then manage it by making a treatment plan. A first component could include consultations with a psychiatrist or psychotherapist.

Treatment and Prevention

The majority of depressions respond to treatment with antidepressants, psychotherapy, or a combination of the 2 treatment methods. Providing information about depression and how to treat it to people who have it, and to their families, can be another part of the treatment plan.

Medication: Sometimes people with depression do not realize that medication could help them, or they are initially reluctant to take antidepressants. However, today there is a whole range of drugs on the market for the treatment of depression. You and your doctor can work together to decide which medicine is best for you.

Among the drugs most commonly used for depression are SSRIs (selective serotonin reuptake inhibitors such as fluoxetine, paroxetine, citalopram, escitalopram), SNRIs (serotonin reuptake inhibitors and norepinephrine such as duloxetine, venlafaxine, and desvenlafaxine), bupropion, trazodone, mirtazapine, MAOIs (monoamine oxidase inhibitors such as moclobemide and phenelzine) and tricyclic antidepressants (eg. amitriptyline, doxepin, nortriptyline).

Medicines used to treat depression start working after 2 to 4 weeks, although some symptoms may improve in the first few weeks. In some circumstances, the initially recommended medication will need to be changed until the signs presented direct the prescription to a more appropriate type of medication. All medicines, including antidepressants, can have side effects. Your doctor and pharmacist should explain the most common side effects to you and help you manage them if they occur. Most antidepressants should be continued for at least 6 to 24 months after the episode of depression resolves.

Herbal remedies: Studies have shown that St. John’s Wort is not effective for people with clinical depression (major depression). Although a few people with mild symptoms may benefit from it, you should still talk to your doctor and pharmacist before taking any herbal or over-the-counter medicine. Note that there may be an interaction between herbal remedies and prescription or over-the-counter medications.

Psychotherapy: Psychotherapy can play an important role in the management of depression. Psychiatrists, psychologists, and some family physicians are trained to help people with depression recognize and overcome the kinds of thoughts that cause depression. Support groups, friends, and family members can also help.

Other treatments:

• in more severe cases, electroconvulsive therapy or ECT is used, but it is usually intended for people who do not respond to antidepressants;
• light therapy or phototherapy (a method that involves controlled exposure to artificial light) may help some people overcome symptoms associated with seasonal affective disorder;
• physical activity and sports can improve a depressed person’s condition by relieving anxiety, increasing appetite, promoting sleep, and improving mood and self-esteem. Physical exercise also increases the production of endorphins, hormones that favorably influence mood;
• an active lifestyle, supportive relationships with family and friends, and a positive outlook for the future can go a long way in helping you cope with depression.

In conclusion

Major depression represents a true medical problem, and depressed patients deserve the best care and a compassionate attitude. The disease is both over-diagnosed and underdiagnosed. During my career, There have been cases where people with the label of major depression have, instead, only struggled through various challenges in their lives. There are also a number of patients who are really depressed, with a lot of very debilitating somatic symptoms, who unfortunately refused treatment which could have been of great help.

Cognitive-behavioral psychotherapy is unfortunately underused due to lack of accessibility. It would be very good if its use could be more widespread.