Clinical depression

What is depression?

Depression is more than simply feeling unhappy or fed up for a few days.

Most people go through periods of feeling down, but when you're depressed you feel persistently sad for weeks or months, rather than just a few days.

Some people think depression is trivial and not a genuine health condition. They're wrong – it's a real illness with real symptoms. Depression isn't a sign of weakness or something you can 'snap out of' by 'pulling yourself together'.

The good news is that with the right treatment and support, most people with depression can make a full recovery.

How to tell if you have depression

Depression affects people in different ways and can cause a wide variety of symptoms.

They range from lasting feelings of unhappiness and hopelessness, to losing interest in the things you used to enjoy and feeling very tearful. Many people with depression also have symptoms of anxiety.

There can be physical symptoms too, such as feeling constantly tired, sleeping badly, having no appetite or sex drive, and various aches and pains.

The symptoms of depression range from mild to severe. At its mildest, you may simply feel persistently low in spirit, while severe depression can make you feel suicidal, that life is no longer worth living.

Most people experience feelings of stress, unhappiness or anxiety during difficult times. A low mood may improve after a short period of time, rather than being a sign of depression. Read more about low mood and depression.

When to see a doctor

It's important to seek help from your doctor if you think you may be depressed.

Many people wait a long time before seeking help for depression, but it's best not to delay. The sooner you see a doctor, the sooner you can be on the way to recovery.

How to talk to your doctor about depression

What causes depression?

Sometimes there's a trigger for depression. Life-changing events, such as bereavement, losing your job or even having a baby, can bring it on.

People with a family history of depression are more likely to experience it themselves. But you can also become depressed for no obvious reason.

Read more about the causes of depression.

Depression is fairly common, affecting about 1 in 10 people at some point during their life. It affects men and women, young and old.

Studies have shown that about 4% of children aged 4 to 16 in the UK are anxious or depressed.

Treating depression

Treatment for depression can involve a combination of lifestyle changes, talking therapies and medication. Your recommended treatment will be based on whether you have mild, moderate or severe depression.

If you have mild depression, your doctor may suggest waiting to see whether it improves on its own, while monitoring your progress. This is known as "watchful waiting". They may also suggest lifestyle measures such as exercise and self-help groups.

Talking therapies, such as cognitive behavioural therapy (CBT), are often used for mild depression that isn't improving or moderate depression. Antidepressants are also sometimes prescribed.

For moderate to severe depression, a combination of talking therapy and antidepressants is often recommended. If you have severe depression, you may be referred to a specialist mental health team for intensive specialist talking treatments and prescribed medication.

Living with depression

Many people with depression benefit by making lifestyle changes, such as getting more exercise, cutting down on alcohol, giving up smoking and eating healthily.

Reading a self-help book or joining a support group are also worthwhile. They can help you gain a better understanding of what causes you to feel depressed. Sharing your experiences with others in a similar situation can also be very supportive.

Read more about the lifestyle changes you can make to help you beat depression.

Depression smptoms

The symptoms of depression can be complex and vary widely between people. But as a general rule, if you're depressed, you feel sad, hopeless and lose interest in things you used to enjoy.

The symptoms persist for weeks or months and are bad enough to interfere with your work, social life and family life.

There are many other symptoms of depression and you're unlikely to have all of those listed below.

Psychological symptoms

The psychological symptoms of depression include:

• continuous low mood or sadness
• feeling hopeless and helpless
• having low self-esteem
• feeling tearful
• feeling guilt-ridden
• feeling irritable and intolerant of others
• having no motivation or interest in things
• finding it difficult to make decisions
• not getting any enjoyment out of life
• feeling anxious or worried
• having suicidal thoughts or thoughts of harming yourself

Physical symptoms

The physical symptoms of depression include:

• moving or speaking more slowly than usual
• changes in appetite or weight (usually decreased, but sometimes increased)
• constipation
• unexplained aches and pains
• lack of energy
• low sex drive (loss of libido)
• changes to your menstrual cycle
• disturbed sleep – for example, finding it difficult to fall asleep at night or waking up very early in the morning

Social symptoms

The social symptoms of depression include:

• not doing well at work
• avoiding contact with friends and taking part in fewer social activities
• neglecting your hobbies and interests
• having difficulties in your home and family life

Severities of depression

Depression can come on gradually, so it can be difficult to notice something is wrong. Many people try to cope with their symptoms without realising they're unwell. It can sometimes take a friend or family member to suggest something is wrong.

Doctors describe depression by how serious it is:

• mild depression – has some impact on your daily life
• moderate depression – has a significant impact on your daily life
• severe depression – makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms

Grief and depression

It can be difficult to distinguish between grief and depression. They share many of the same characteristics, but there are important differences between them.

Grief is an entirely natural response to a loss, while depression is an illness.

People who are grieving find their feelings of sadness and loss come and go, but they're still able to enjoy things and look forward to the future.

In contrast, people who are depressed constantly feel sad. They don't enjoy anything and find it difficult to be positive about the future.

Read more about coping with bereavement.

Other types of depression

There are different types of depression and there are also some conditions where depression may be one of the symptoms. These include:

• postnatal depression – some women develop depression after having a baby. This is known as postnatal depression and is treated in a similar way to other types of depression, with talking therapies and antidepressant medicines
• bipolar disorder – also known as 'manic depression'. In bipolar disorder there are spells of both depression and excessively high mood (mania); the depression symptoms are similar to clinical depression, but the bouts of mania can include harmful behaviour, such as gambling, going on spending sprees and having unsafe sex
• seasonal affective disorder (SAD) – also known as "winter depression", SAD is a type of depression with a seasonal pattern usually related to winter

Read more about diagnosing depression.

Causes of depression

There's no single cause of depression. It can occur for a variety of reasons and it has many different triggers.

For some people, an upsetting or stressful life event, such as bereavement, divorce, illness, redundancy and job or money worries, can be the cause.

Different causes can often combine to trigger depression. For example, you may feel low after being ill and then experience a traumatic event, such as a bereavement, which brings on depression.

People often talk about a 'downward spiral' of events that leads to depression. For example, if your relationship with your partner breaks down, you're likely to feel low, you may stop seeing friends and family, and you may start drinking more. All of this can make you feel worse and trigger depression.

Some studies have suggested you're more likely to get depression as you get older, and that it's more common in people who live in difficult social and economic circumstances.

Some of the potential triggers of depression are discussed below.

Stressful events

Most people take time to come to terms with stressful events, such as bereavement or a relationship breakdown. When these stressful events occur, your risk of becoming depressed increases if you stop seeing your friends and family and try to deal with your problems on your own.

Personality

You may be more vulnerable to depression if you have certain personality traits, such as low self-esteem or being overly self-critical. This may be because of the genes you've inherited from your parents, your early life experiences, or both.

Family history

If someone in your family has had depression in the past, such as a parent or sister or brother, it's more likely that you'll also develop it.

Giving birth

Some women are particularly vulnerable to depression after pregnancy. The hormonal and physical changes, as well as the added responsibility of a new life, can lead to postnatal depression.

Loneliness

Becoming cut off from your family and friends can increase your risk of depression.

Alcohol and drugs

When life is getting them down, some people try to cope by drinking too much alcohol or taking drugs. This can result in a spiral of depression.

Cannabis can help you relax, but there's evidence that it can bring on depression, particularly in teenagers.

'Drowning your sorrows' with a drink is not recommended. Alcohol is categorised as a strong depressant, which actually makes depression worse.

Illness

You may have a higher risk of depression if you have a longstanding or life-threatening illness, such as coronary heart disease or cancer.

Head injuries are also an often under-recognised cause of depression. A severe head injury can trigger mood swings and emotional problems.

Some people may have an underactive thyroid (hypothyroidism) resulting from problems with their immune system. In rarer cases, a minor head injury can damage the pituitary gland, which is a pea-sized gland at the base of your brain that produces thyroid-stimulating hormones.

This can cause a number of symptoms, such as extreme tiredness and a lack of interest in sex (loss of libido), which can in turn lead to depression.

Diagnosing depression

If you experience symptoms of depression for most of the day, every day for more than 2 weeks, you should seek help from your doctor.

It's particularly important to speak to your doctor if you:

• have symptoms of depression that aren't improving
• find your mood affects your work, other interests, and relationships with your family and friends
• have thoughts of suicide or self-harm

Sometimes, when you're depressed it can be difficult to imagine that treatment can actually help. But the sooner you seek treatment, the sooner your depression will improve.

There are no physical tests for depression, but your doctor may examine you and carry out some urine or blood tests to rule out other conditions that have similar symptoms, such as an underactive thyroid.

The main way your doctor will tell if you have depression is by asking you lots of questions about your general health and how the way you're feeling is affecting you mentally and physically.

Try to be as open and honest as you can be with your answers. Describing your symptoms and how they're affecting you will help your doctor determine whether you have depression and how severe it is.

Any discussion you have with your doctor will be confidential. This rule will only ever be broken if there's a significant risk of harm to either yourself or others, and if informing a family member or carer would reduce that risk.

Read about treating clinical depression.

Treatment for depression

Talking treatments

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) aims to help you understand your thoughts and behaviour and how they affect you.

CBT recognises that events in your past may have shaped you, but it concentrates mostly on how you can change the way you think, feel and behave in the present.

It teaches you how to overcome negative thoughts – for example, being able to challenge hopeless feelings.

CBT is available on the NHS for people with depression or any other mental health problem that it's been shown to help.

You normally have a short course of sessions, usually 6 to 8 sessions, over 10 to 12 weeks on a one-to-one basis with a counsellor trained in CBT. In some cases, you may be offered group CBT.

Online CBT

Online CBT is a type of CBT that's delivered through a computer, rather than face-to-face with a therapist.

You'll have a series of weekly sessions and you should receive support from a healthcare professional. For example, online CBT is usually prescribed by your doctor and you may have to use the surgery computer to access the programme.

Ask your doctor for more information or read more about online CBT and the courses available.

Interpersonal therapy (IPT)

Interpersonal therapy (IPT) focuses on your relationships with others and on problems you may be having in your relationships, such as difficulties with communication or coping with bereavement.

There's some evidence that IPT can be as effective as antidepressants or CBT, but more research is needed.

Psychodynamic psychotherapy

In psychodynamic (psychoanalytic) psychotherapy, a psychoanalytic therapist will encourage you to say whatever is going through your mind.

This will help you become aware of hidden meanings or patterns in what you do or say that may be contributing to your problems.

Read more about psychotherapy.

Counselling

Counselling is a form of therapy that helps you think about the problems you're experiencing in your life so you can find new ways of dealing with them. Counsellors support you in finding solutions to problems but don't tell you what to do.

Counselling on the NHS usually consists of 6 to 12 hour-long sessions. You talk in confidence to a counsellor, who supports you and offers practical advice.

Counselling is ideal for people who are basically healthy but need help coping with a current crisis, such as anger, relationship issues, bereavement, redundancy, infertility or a serious illness.

Getting help

See your doctor for more information. They can refer you for local talking treatments for depression. You also have the option of self-referral. This means that if you prefer not to talk to your doctor, you can go directly to a professional therapist.

Antidepressants

Antidepressants are medicines that treat the symptoms of depression. There are almost 30 different types available.

Most people with moderate or severe depression benefit from antidepressants, but not everybody does. You may respond to one antidepressant but not to another, and you may need to try 2 or more treatments before you find one that works for you.

The different types of antidepressants work about as well as each other. However, side effects vary between different treatments and people.

When you start taking antidepressants, you should see your doctor or specialist nurse every week or 2 for at least 4 weeks to assess how well they're working. If they're working, you'll need to continue taking them at the same dose for at least 4 to 6 months after your symptoms have eased.

If you've had episodes of depression in the past, you may need to continue to take antidepressants for up to 5 years or longer.

Antidepressants aren't addictive, but you may get some withdrawal symptoms if you stop taking them suddenly or you miss a dose (see below).

Selective serotonin reuptake inhibitors (SSRIs)

If your doctor thinks you would benefit from taking an antidepressant, you'll usually be prescribed a modern type called a selective serotonin reuptake inhibitor (SSRI). Examples of commonly used SSRI antidepressants are paroxetine (Seroxat), fluoxetine (Prozac) and citalopram (Cipramil).

They help increase the level of a natural chemical in your brain called serotonin, which is thought to be a 'good mood' chemical.

SSRIs work just as well as older antidepressants and have fewer side effects, although they can cause nausea, headaches, a dry mouth, and problems having sex. However, these side effects usually improve over time.

Some SSRIs aren't suitable for children and young people under 18 years of age. Research shows that the risk of self-harm and suicidal behaviour may increase if they're taken by under-18s. Fluoxetine is the only SSRI that can be prescribed for under-18s, and even then only when a specialist has given the go-ahead.

Vortioxetine (Brintellix or Lundbeck) is an SSRI that's recommended by the National Institute for Health and Care Excellence (NICE) for treating severe depression in adults.

Common side effects associated with vortioxetine include abnormal dreams, constipation, diarrhoea, dizziness, itching, nausea and vomiting.

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs) are a group of antidepressants that are used to treat moderate to severe depression.

TCAs, including imipramine (Imipramil) and amitriptyline, have been around for longer than SSRIs.

They work by raising the levels of the chemicals serotonin and noradrenaline in your brain. These both help lift your mood.

Side effects of TCAs vary from person to person but may include a dry mouth, blurred vision, constipation, problems passing urine, sweating, light-headedness and excessive drowsiness.

The side effects usually ease after 7 to 10 days, as your body gets used to the medication.

Other antidepressants

New antidepressants, such as venlafaxine (Efexor), duloxetine (Cymbalta or Yentreve) and mirtazapine (Zispin Soltab), work in a slightly different way from SSRIs and TCAs.

Venlafaxine and duloxetine are known as serotonin-noradrenaline reuptake inhibitors (SNRIs). Like TCAs, they change the levels of serotonin and noradrenaline in your brain.

Studies have shown that an SNRI can be more effective than an SSRI, but they're not routinely prescribed because they can lead to a rise in blood pressure.

Withdrawal symptoms

Antidepressants aren't addictive in the same way that illegal drugs and cigarettes are, but when you stop taking them you may have some withdrawal symptoms, including:

• upset stomach
• flu-like symptoms
• anxiety
• dizziness
• vivid dreams at night
• sensations in the body that feel like electric shocks

In most cases, these are quite mild and last no longer than a week or 2, but occasionally they can be quite severe. They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Efexor).

Withdrawal symptoms occur very soon after stopping the tablets, so are easy to distinguish from symptoms of depression relapse, which tend to occur after a few weeks.

Other treatments

Mindfulness

Mindfulness involves paying closer attention to the present moment and focusing on your thoughts, feelings, bodily sensations, and the world around you to improve your mental wellbeing.

The aim is to develop a better understanding of your mind and body and learn how to live with more appreciation and less anxiety.

Mindfulness is recommended by the National Institute for Health and Care Excellence (NICE) as a way of preventing depression in people who've had 3 or more bouts of depression in the past.

Read more about mindfulness.

St John's wort

St John's wort is a herbal treatment that some people take for depression. It's available from health food shops and pharmacies.

There's some evidence that it may help mild to moderate depression, but it's not recommended by doctors. This is because the amount of active ingredients varies among individual brands and batches, so you can never be sure what sort of effect it will have on you.

Taking St John's wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems.

You shouldn't take St John's wort if you're pregnant or breastfeeding, as we don't know for sure that it's safe.

St John's wort can interact with the contraceptive pill, reducing its contraceptive effect.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is sometimes recommended in cases of severe depression where other treatments, including antidepressants, haven't worked.

For most people, ECT is effective at relieving severe depression, although the beneficial effect tends to wear off after several months.

Some people also experience unpleasant side effects after having ECT, including short-term headaches, memory problems, nausea and muscle aches.

There are 2 types of ECT recommended by NICE – transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS).

Transcranial direct current stimulation (tDCS)

Transcranial direct current stimulation (tDCS) involves placing electrodes on your head.

The electrodes are attached to a small, portable battery-operated stimulator which delivers a constant, low-strength current to the brain. The electric current stimulates brain activity to help improve the symptoms of depression.

You'll remain awake and alert throughout the procedure, which is usually carried out by a trained clinician. However, it's sometimes possible for tDCS to be self-administered. The treatment can be used on its own or in addition to other treatments for depression.

Treatment sessions are carried out daily and last for about 20-30 minutes, with a course of treatment typically lasting several weeks.

Treatment with tDCS is safe and has been found to be effective in some cases. There's some uncertainty about the way tDCS is delivered, the number of treatments needed, and how long its effects last, so further research in these areas is needed.

Repetitive transcranial magnetic stimulation (rTMS)

Repetitive transcranial magnetic stimulation (rTMS) involves holding an electromagnetic coil against your head, which delivers repetitive pulses of electromagnetic energy at various frequencies or intensities. This stimulates a part of the brain called the cerebral cortex.

Treatment with rTMS usually involves a 2 to 6-week course of daily sessions that last about 30 minutes.

Evidence suggests that rTMS for depression is safe, although the effectiveness of treatment can vary between individuals.

Lithium

If you've tried several different antidepressants and there's been no improvement, your doctor may offer you a type of medication called lithium in addition to your current treatment.

There are 2 types of lithium – lithium carbonate and lithium citrate. Both are usually effective, but if you're taking one that works for you, it's best not to change.

If the level of lithium in your blood becomes too high, it can become toxic. You'll therefore need blood tests every 3 months to check your lithium levels while you're on the medication.

You'll also need to avoid eating a low-salt diet because it can also cause the lithium to become toxic. Ask your doctor for advice about your diet.

Psychotic depression

Some people who have severe clinical depression will also experience hallucinations and delusional thinking, the symptoms of psychosis.

Depression with psychosis is known as psychotic depression.

Symptoms of severe depression

Someone with severe clinical depression feels sad and hopeless for most of the day, practically every day, and has no interest in anything. Getting through the day feels almost impossible.

Other typical symptoms of severe depression are:

• fatigue (exhaustion)
• loss of pleasure in things
• disturbed sleep
• changes in appetite
• feeling worthless and guilty
• being unable to concentrate or being indecisive
• thoughts of death or suicide

Read more about the psychological, physical and social symptoms of clinical depression.

Symptoms of psychosis

Having moments of psychosis (psychotic episodes) means experiencing:

• delusions – thoughts or beliefs that are unlikely to be true
• hallucinations – hearing and, in some cases, feeling, smelling, seeing or tasting things that aren't there; hearing voices is a common hallucination

The delusions and hallucinations almost always reflect the person's deeply depressed mood – for example, they may become convinced they're to blame for something, or that they've committed a crime.

'Psychomotor agitation' is also common. This means not being able to relax or sit still, and constantly fidgeting.

At the other extreme, a person with psychotic depression may have 'psychomotor retardation', where both their thoughts and physical movements slow down.

People with psychotic depression have an increased risk of thinking about suicide.

What causes psychotic depression?

The cause of psychotic depression isn't fully understood. It's known that there's no single cause of depression and it has many different triggers.

For some, stressful life events such as bereavement, divorce, serious illness or financial worries can be the cause.

Genes probably play a part, as severe depression can run in families, although it's not known why some people also develop psychosis.

Many people with psychotic depression will have experienced adversity in childhood, such as a traumatic event.

Read more about the causes of clinical depression.

Treating psychotic depression

Treatment for psychotic depression involves:

• medication – a combination of antipsychotics and antidepressants can help relieve the symptoms of psychosis
• psychological therapies – the one-to-one talking therapy cognitive behavioural therapy (CBT) has proved effective in helping some people with psychosis
• social support – support with social needs, such as education, employment or accommodation

The person may need to stay in hospital for a short period of time while they're receiving treatment.

Electroconvulsive therapy (ECT) may sometimes be recommended if the person has severe depression and other treatments, including antidepressants, haven't worked.

Treatment is usually effective, but follow-up appointments so that the person can be closely monitored are usually required.

Getting help for others

People with psychosis are often unaware that they're thinking and acting strangely.

As a result of this lack of insight, it's often down to the person's friends, relatives or carers to seek help for them.

If you're concerned about someone and think they may have psychosis, you could contact their social worker or community mental health nurse if they've previously been diagnosed with a mental health condition.

Contact the person's doctor if this is the first time they've shown symptoms of psychosis.

If you think the person's symptoms are placing them or others at possible risk of harm you can:

• take them to your nearest accident and emergency (A&E) department, if they agree
• call their doctor or local out-of-hours doctor
• call for an ambulance

Living with

Talking about it

Sharing a problem with someone else or with a group can give you support and an insight into your own depression. Research shows that talking can help people recover from depression and cope better with stress.

You may not feel comfortable discussing your mental health and sharing your distress with others. If this is the case, writing about how you feel or expressing your emotions through poetry or art are other ways to help your mood.

Smoking, drugs and alcohol

If you have depression it may be tempting to smoke or drink to make you feel better. Cigarettes and alcohol may seem to help at first, but they make things worse in the long run.

Be extra cautious with cannabis. You might think it's harmless, but research has shown a strong link between cannabis use and mental illness, including depression.

The evidence shows that if you smoke cannabis you:

• make your depression symptoms worse
• feel more tired and uninterested in things
• are more likely to have depression that relapses earlier and more frequently
• won't have as good a response to antidepressant medicines
• are more likely to stop using antidepressant medicines
• are less likely to fully recover

Your doctor can give you advice and support if you drink or smoke too much or use drugs.

You may also find the following pages useful:

• stop smoking: coping with cravings
• getting help for drug addiction
• alcohol support

Work and finances

If your depression is caused by working too much or if it's affecting your ability to do your job, you may need time off to recover.

However, there's evidence to suggest that taking prolonged time off work can make depression worse. There's also quite a bit of evidence to support that going back to work can help you recover from depression.

It's important to avoid too much stress, and this includes work-related stress. If you're employed, you may be able to work shorter hours or work in a more flexible way, particularly if job pressures seem to trigger your symptoms.

Looking after someone with depression

It's not just the person with depression who's affected by their illness. The people close to them are also affected.

If you're caring for someone with depression, your relationship with them and family life in general can become strained. You may feel at a loss as to what to do. Finding a support group and talking to others in a similar situation might help.

If you're having relationship or marriage difficulties, it might help to contact a relationship counsellor who can talk things through with you and your partner.

Men are less likely to ask for help than women and are also more likely to turn to alcohol or drugs when depressed.

Coping with bereavement

Losing someone close to you can be a trigger for depression.

When someone you love dies, the sense of loss can be so powerful that you feel it's impossible to recover. However, with time and the right help and support, it's possible to start living your life again.

Find out more about coping with bereavement.

Depression and suicide

The majority of suicide cases are linked with mental disorders, and most of them are triggered by severe depression.

Warning signs that someone with depression may be considering suicide include:

• making final arrangements, such as giving away possessions, making a will or saying goodbye to friends
• talking about death or suicide – this may be a direct statement, such as "I wish I was dead", but often depressed people will talk about the subject indirectly, using phrases like "I think dead people must be happier than us" or "wouldn't it be nice to go to sleep and never wake up"
• self-harm, such as cutting their arms or legs, or burning themselves with cigarettes
• a sudden lifting of mood, which could mean that a person has decided to attempt suicide and feels better because of this decision

Contact your doctor as soon as possible if you're feeling suicidal or are in the crisis of depression. They'll be able to help you.

Helping a suicidal friend or relative

If you see any of the above warning signs in a friend or relative:

• get professional help for them
• let them know they aren't alone and you care about them
• offer support in finding other solutions to their problems

If you feel there's an immediate danger, stay with the person or have someone else stay with them, and remove all available means of committing suicide, such as medication.

Over-the-counter medication, such as painkillers, can be just as dangerous as prescription medication. Also, remove sharp objects and poisonous household chemicals such as bleach.