About this booklet

This booklet, prepared by the National Institute of Mental Health (NIMH), provides an overview on depression. NIMH is part of the National Institutes of Health (NIH), the primary Federal agency for conducting and supporting medical research.

This booklet will help you learn the following four things that everyone should know about depression:

• Depression is a real illness.
• Depression affects people in different ways.
• Depression is treatable.
• If you have depression, you are not alone.

This booklet contains information on the signs and symptoms of depression, treatment and support options, and a listing of additional resources. It is intended for informational purposes only and should not be considered a guide for making medical decisions. Please review this information and discuss it with your doctor or health care provider. For more information on depression, please visit the NIMH website atwww.nimh.nih.gov.

Need help now?

Call the 24-hour, toll-free confidential National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or go towww.suicidepreventionlifeline.org .

Depression is a real illness.

Sadness is something we all experience. It is a normal reaction to difficult times in life and usually passes with a little time.

When a person has depression, it interferes with daily life and normal functioning. It can cause pain for both the person with depression and those who care about him or her. Doctors call this condition “depressive disorder,” or “clinical depression.” It is a real illness. It is not a sign of a person’s weakness or a character flaw. You can’t “snap out of” clinical depression. Most people who experience depression need treatment to get better.

Signs and Symptoms

Sadness is only a small part of depression. Some people with depression may not feel sadness at all. Depression has many other symptoms, including physical ones. If you have been experiencing any of the following signs and symptoms for at least 2 weeks, you may be suffering from depression:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities
• Decreased energy, fatigue, being “slowed down”
• Difficulty concentrating, remembering, making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Thoughts of death or suicide, suicide attempts
• Restlessness, irritability
• Persistent physical symptoms

Factors That Play a Role in Depression

Many factors may play a role in depression, including genetics, brain biology and chemistry, and life events such as trauma, loss of a loved one, a difficult relationship, an early childhood experience, or any stressful situation.

Depression can happen at any age, but often begins in the teens or early 20s or 30s. Most chronic mood and anxiety disorders in adults begin as high levels of anxiety in children. In fact, high levels of anxiety as a child could mean a higher risk of depression as an adult.

Depression can co-occur with other serious medical illnesses such as diabetes, cancer, heart disease, and Parkinson’s disease. Depression can make these conditions worse and vice versa. Sometimes medications taken for these illnesses may cause side effects that contribute to depression. A doctor experienced in treating these complicated illnesses can help work out the best treatment strategy.

Research on depression is ongoing, and one day these discoveries may lead to better diagnosis and treatment. To learn more about current research, visit the NIMH website at www.nimh.nih.gov.

Types of Depression

There are several types of depressive disorders.

Major depression: Severe symptoms that interfere with the ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes.

Persistent depressive disorder: A depressed mood that lasts for at least 2 years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for 2 years.

Some forms of depression are slightly different, or they may develop under unique circumstances. They include:

Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others cannot hear or see (hallucinations).

Postpartum depression, which is much more serious than the “baby blues” that many women experience after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Bipolar disorder is different from depression. The reason it is included in this list is because someone with bipolar disorder experiences episodes of extreme low moods (depression). But a person with bipolar disorder also experiences extreme high moods (called “mania”).

You can learn more about many of these disorders on the NIMH website at www.nimh.nih.gov.

Depression affects people in different ways.

Not everyone who is depressed experiences every symptom. Some people experience only a few symptoms. Some people have many. The severity and frequency of symptoms, and how long they last, will vary depending on the individual and his or her particular illness. Symptoms may also vary depending on the stage of the illness.

Women

Women with depression do not all experience the same symptoms. However, women with depression typically have symptoms of sadness, worthlessness, and guilt.

Depression is more common among women than among men. Biological, lifecycle, hormonal, and psychosocial factors that are unique to women may be linked to their higher depression rate. For example, women are especially vulnerable to developing postpartum depression after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming.

Men

Men often experience depression differently than women. While women with depression are more likely to have feelings of sadness, worthlessness, and excessive guilt, men are more likely to be very tired, irritable, lose interest in once-pleasurable activities, and have difficulty sleeping.

Men may turn to alcohol or drugs when they are depressed. They also may become frustrated, discouraged, irritable, angry, and sometimes abusive. Some men may throw themselves into their work to avoid talking about their depression with family or friends, or behave recklessly. And although more women attempt suicide, many more men die by suicide in the United States.

Children

Before puberty, girls and boys are equally likely to develop depression. A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary “phase” or is suffering from depression. Sometimes the parents become worried about how the child’s behavior has changed, or a teacher mentions that “your child doesn’t seem to be himself.” In such a case, if a visit to the child’s pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a mental health professional who specializes in the treatment of children. Most chronic mood disorders, such as depression, begin as high levels of anxiety in children.

Teens

The teen years can be tough. Teens are forming an identity apart from their parents, grappling with gender issues and emerging sexuality, and making independent decisions for the first time in their lives. Occasional bad moods are to be expected, but depression is different.

Older children and teens with depression may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. If you’re unsure if an adolescent in your life is depressed or just “being a teenager,” consider how long the symptoms have been present, how severe they are, and how different the teen is acting from his or her usual self. Teens with depression may also have other disorders such as anxiety, eating disorders, or substance abuse. They may also be at higher risk for suicide.

Children and teenagers usually rely on parents, teachers, or other caregivers to recognize their suffering and get them the treatment they need. Many teens don’t know where to go for mental health treatment or believe that treatment won’t help. Others don’t get help because they think depression symptoms may be just part of the typical stress of school or being a teen. Some teens worry what other people will think if they seek mental health care.

Depression often persists, recurs, and continues into adulthood, especially if left untreated. If you suspect a child or teenager in your life is suffering from depression, speak up right away.

Quick Tips for Talking to Your Depressed Child or Teen:

• Offer emotional support, understanding, patience, and encouragement.
• Talk to your child, not necessarily about depression, and listen carefully.
• Never discount the feelings your child expresses, but point out realities and offer hope.
• Never ignore comments about suicide.
• Remind your child that with time and treatment, the depression will lift.

Older People

Having depression for a long period of time is not a normal part of growing older. Most older adults feel satisfied with their lives, despite having more illnesses or physical problems. But depression in older adults may be difficult to recognize because they may show different, less obvious symptoms.

Sometimes older people who are depressed appear to feel tired, have trouble sleeping, or seem grumpy and irritable. Confusion or attention problems caused by depression can sometimes look like Alzheimer’s disease or other brain disorders. Older adults also may have more medical conditions such as heart disease, stroke, or cancer, which may cause depressive symptoms. Or they may be taking medications with side effects that contribute to depression.

Some older adults may experience what doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. The hardening of vessels prevents normal blood flow to the body’s organs, including the brain. Those with vascular depression may have or be at risk for heart disease or stroke.

Sometimes it can be difficult to distinguish grief from major depression. Grief after loss of a loved one is a normal reaction and generally does not require professional mental health treatment. However, grief that is complicated and lasts for a very long time following a loss may require treatment.

Older adults who had depression when they were younger are more at risk for developing depression in late life than those who did not have the illness earlier in life.

Depression is treatable.

Depression, even the most severe cases, can be treated. The earlier treatment begins, the more effective it is. Most adults see an improvement in their symptoms when treated with antidepressant drugs, talk therapy (psychotherapy), or a combination of both.

If you think you may have depression, start by making an appointment to see your doctor or health care provider. This could be your primary doctor or a health provider who specializes in diagnosing and treating mental health conditions (psychologist or psychiatrist). Certain medications, and some medical conditions, such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by doing a physical exam, interview, and lab tests. If the doctor can find no medical condition that may be causing the depression, the next step is a psychological evaluation.

Quick Tip: Making an Appointment

If you still need to make an appointment, here are some things you could say during the first call: “I haven’t been myself lately, and I’d like to talk to the provider about it,” or “I think I might have depression, and I’d like some help.”

Talking to Your Doctor

How well you and your doctor talk to each other is one of the most important parts of getting good health care. But talking to your doctor isn’t always easy. It takes time and effort on your part as well as your doctor’s.

To prepare for your appointment, make a list of:

• Any symptoms you’ve had, including any that may seem unrelated to the reason for your appointment
  • When did your symptoms start?
  • How severe are your symptoms?
  • Have the symptoms occurred before?
  • If the symptoms have occurred before, how were they treated?
• Key personal information, including any major stresses or recent life changes
• All medications, vitamins, or other supplements that you’re taking, including how much and how often
• Questions to ask your health provider

If you don’t have a primary doctor or are not at ease with the one you currently see, now may be the time to find a new doctor. Whether you just moved to a new city, changed insurance providers, or had a bad experience with your doctor or medical staff, it is worthwhile to spend time finding a doctor you can trust.

Tests and Diagnosis

Your doctor or health care provider will examine you and talk to you at the appointment. Your doctor may do a physical exam and ask questions about your health and symptoms. There are no lab tests that can specifically diagnose depression, but your doctor may also order some lab tests to rule out other conditions.

Ask questions if the doctor’s explanations or instructions are unclear, bring up problems even if the doctor doesn’t ask, and let the doctor know if you have concerns about a particular treatment or change in your daily life.

Your doctor may refer you to a mental health professional, such as a psychiatrist, psychologist, social worker, or mental health counselor, who should discuss with you any family history of depression or other mental disorder, and get a complete history of your symptoms. The mental health professional may also ask if you are using alcohol or drugs, and if you are thinking about death or suicide. If your doctor does not refer you to a mental health professional or you feel your concerns were not adequately addressed, call or visit the website for your health insurance provider, Medicare (www.medicare.gov/ ), or Medicaid (http://medicaid.gov/ ). You can also try searching in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Behavioral Health Treatment Services Locator (https://findtreatment.samhsa.gov/ ) or one of the other resources listed at the end of this booklet to find one.

Need Help Now?

Call the 24-hour, toll-free confidential National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or go towww.suicidepreventionlifeline.org .

Treatment

Depression is treated with medicines, talk therapy (where a person talks with a trained professional about his or her thoughts and feelings; sometimes called “psychotherapy”), or a combination of the two. Remember: No two people are affected the same way by depression. There is no “one-size-fits-all” for treatment. It may take some trial and error to find the treatment that works best for you.

Medications

Quick Tip: Medications

Because information about medications is always changing, the following section may not list all the types of medications available to treat depression. Check the Food and Drug Administration (FDA) website (www.fda.gov ) for the latest news and information on warnings, patient medication guides, or newly approved medications.

Antidepressants are medicines that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress.

There are several types of antidepressants:

• Selective serotonin reuptake inhibitors (SSRI)
• Serotonin and norepinephrine reuptake inhibitors (SNRI)
• Tricyclic antidepressants (TCA)
• Monoamine oxidase inhibitors (MAOI)

There are other antidepressants that don’t fall into any of these categories and are considered unique, such as Mirtazapine and Bupropion.

Although all antidepressants can cause side effects, some are more likely to cause certain side effects than others. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has side effects that you can manage.

Most antidepressants are generally safe, but the U.S. Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers, and young adults under age 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

Common side effects listed by the FDA for antidepressants are:

• Nausea and vomiting
• Weight gain
• Diarrhea
• Sleepiness
• Sexual problems

Other more serious but much less common side effects listed by the FDA for antidepressant medicines can include seizures, heart problems, and an imbalance of salt in your blood, liver damage, suicidal thoughts, or serotonin syndrome (a life-threatening reaction where your body makes too much serotonin). Serotonin syndrome can cause shivering, diarrhea, fever, seizures, and stiff or rigid muscles.

Your doctor may have you see a talk therapist in addition to taking medicine. Ask your doctor about the benefits and risks of adding talk therapy to your treatment. Sometimes talk therapy alone may be the best treatment for you.

If you are having suicidal thoughts or other serious side effects like seizures or heart problems while taking antidepressant medicines, contact your doctor immediately.

The National Suicide Prevention Lifeline is available at 1-800-273-TALK (8255), or you can visitwww.suicidepreventionlifeline.org .

How Should Antidepressants Be Taken?

People taking antidepressants need to follow their doctor’s directions. The medication should be taken in the right dose for the right amount of time. It can take 3 or 4 weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It’s important to give the body time to adjust to the change. People don’t get addicted, or “hooked,” on the medications, but stopping them abruptly can cause withdrawal symptoms. If a medication does not work, it may be helpful to be open to trying another one.

FDA Warning on Antidepressants

Antidepressants are generally considered safe, but some studies have suggested that they may have unintentional effects, especially in young people. The FDA adopted a “black box” warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or suicide attempts in children, adolescents, and young adults up through age 24.

The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor.

Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly used “triptan” medications used to treat migraine headaches could cause a life-threatening illness called “serotonin syndrome.” A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

The benefits of antidepressant medications may outweigh their risks to children and adolescents with depression. To find the latest information, talk to your doctor and visit www.fda.gov .

Are Herbal Medicines Used to Treat Depression?

You may have heard about an herbal medicine called St. John’s wort. St. John’s wort is an herb. Its flowers and leaves are used to make medicine. It is one of the top-selling botanical products in the United States. But St. John’s wort is not a proven therapy for depression. The FDA has not approved its use as an over-the-counter or prescription medicine for depression, and there are serious concerns about its safety and effectiveness.

Taking St. John’s wort can weaken many prescription medicines, such as:

• Antidepressants
• Birth control pills
• Cyclosporine, which prevents the body from rejecting transplanted organs
• Digoxin, a heart medication
• Some HIV drugs
• Some cancer medications
• Medications used to thin the blood

Quick Tip: If You Are Considering St. John’s Wort for Depression

• Do not use St. John’s wort to replace conventional care or to postpone seeing a health care provider. If not adequately treated, depression can become severe.
• Keep in mind that dietary supplements can cause medical problems if not used correctly or if used in large amounts, and some may interact with medications you take. Your health care provider can advise you.
• Many dietary supplements have not been tested in pregnant women, nursing mothers, or children. Little safety information on St. John’s wort for pregnant women or children is available, so it is especially important to talk with health experts if you are pregnant or nursing or are considering giving a dietary supplement to a child.
• Tell all your health care providers about any complementary health approaches you use. Give them a full picture of what you do to manage your health.

For more information, please visit the website for the National Center for Complementary and Integrative Health at https://nccih.nih.gov/ .

For more information on medications for depression, please visit the FDA website at http://www.fda.gov. You can also find information on drugs, supplements, and herbal information on the National Library of Medicine’s Medline Plus website (www.nlm.nih.gov/medlineplus/druginformation.html ).

Talk Therapy (“Psychotherapy”)

Several types of psychotherapy—or “talk therapy”—can help people with depression. There are several types of psychotherapies that may be effective in treating depression. Examples include cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy.

Cognitive-Behavioral Therapy (CBT)

CBT can help an individual with depression change negative thinking. It can help you interpret your environment and interactions in a positive, realistic way. It may also help you recognize things that may be contributing to the depression and help you change behaviors that may be making the depression worse.

Interpersonal Therapy (IPT)

IPT is designed to help an individual understand and work through troubled relationships that may cause the depression or make it worse. When a behavior is causing problems, IPT may help you change the behavior. In IPT, you explore major issues that may add to your depression, such as grief, or times of upheaval or transition.

Problem-Solving Therapy (PST)

PST can improve an individual’s ability to cope with stressful life experiences. It is an effective treatment option, particularly for older adults with depression. Using a step-by-step process, you identify problems and come up with realistic solutions. It is a short-term therapy and may be conducted in an individual or group format.

For mild to moderate depression, psychotherapy may be the best option. However, for severe depression or for certain people, psychotherapy may not be enough. For teens, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the chances of it coming back. Another study looking at depression treatment among older adults found that people who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least 2 years.

More information on psychotherapy is available on the NIMH website atwww.nimh.nih.gov/health/topics/psychotherapies/index.shtml.

Computer and/or Internet-Based Therapies

Your therapist could be only a mouse click or email away. There are many therapy programs available online or on the computer (e.g., DVDs, CDs), and some research shows that Internet-based therapies may be just as helpful as face-to-face. But results can vary from program to program, and each program is different.

Many of these therapies are based on the two main types of psychotherapies—CBT and IPT. But they may be in different formats.

For example, you might learn from materials online and get support from your therapist by email. It could be a video conferencing session that progresses much like a face-to-face session. Or you may use a computer program with video, quizzes, and other features with very little contact with a therapist. Sometimes these therapies are used along with face-to-face sessions. Sometimes they are not.

There are pros to receiving therapy on the Internet or on the computer. These options could provide more access to care if you live in a rural area where providers aren’t available or if you have trouble fitting sessions into your schedule. Also, tech-savvy teens who feel uncomfortable with office visits may be more open to talking to a therapist through a computer screen.

There are also cons. For example, your health insurance may only cover therapy that is face-to-face. And although these various formats may work for a range of patients, they also may not be right for certain patients depending on a variety of factors.

If you are interested in exploring Internet or computer-based therapy, talk to your doctor or mental health provider. You may also be able to find an online mental health care provider on your own. But remember that there are many online “therapists” who may lack the proper training or who may try to take advantage of you. Speak with your provider first to see if he or she can provide a recommendation or trusted source for more information. You can also check the online provider’s credentials and ask about his or her treatment approach. Sometimes you may need to have a conversation with more than one provider to find the right one for you. If cost is an issue, be sure to also contact your health insurance provider to see what’s covered and what’s not.

Depression: Is There an App for That?

If you have a smartphone, tablet, or “phablet” (phone tablets), you may have noticed that there are many mobile applications, or apps, marketed as support for people with depression. Some of these apps aim to provide treatment and education. Other apps offer tools to help you assess yourself, manage your symptoms, and explore resources.

With a few taps on the screen, you could have information and tools to help your depression in the palm of your hand. But, just like with online health information, it is important to find an app that you can trust.

Here are a few things that are important to remember about mobile apps for depression:

• Some apps provide reliable, science-based health information and tools. Some do not.
• Some app developers consult doctors, researchers, and other experts to develop their app. Others do not.
• A mobile app should not replace seeing your doctor or other health care provider.
• Talk to your doctor before making any changes recommended by any online or mobile source.

Quick Tip: Questions to Ask Before Using a Mobile Health App:

• Who developed the app? Is that information easy to find?
• Who wrote and/or reviews the information?
• Is your privacy protected? Does the app clearly state a privacy policy?
• Does the website offer quick and easy solutions to your health problems? Are miracle cures promised?

Does the FDA Regulate Mobile Apps?

Many mobile apps for depression provide information or general patient educational tools. Because these are not considered medical devices, the FDA does not regulate them.

Some mobile apps carry minimal risks to consumers or patients, but others can carry significant risks if they do not operate correctly. The FDA is focusing its oversight on mobile medical apps that:

• Are intended to be used as an accessory to a regulated medical device—for example, an app that allows a health care professional to make a specific diagnosis by viewing a medical image from a picture archiving and communication system on a smartphone or a mobile tablet.
• Transform a mobile platform into a regulated medical device—for example, an app that turns a smartphone into an electrocardiograph (ECG) machine to detect abnormal heart rhythms or determine if a patient is experiencing a heart attack.

Does NIMH Have an App for Depression?

NIMH does not currently offer any mobile apps, but NIMH’s website, www.nimh.nih.gov, is mobile-friendly. This means you can access the NIMH website anywhere, anytime, and on any device—from desktop computers to tablets and mobile phones.

If you see an app that claims to be created or reviewed by NIMH, please call the NIMH Information Resource Center to verify that it was developed or reviewed by us.

NIMH Information Resource Center

Telephone:

• 1-866-615-6464 (toll-free)
• 1-301-443-8431 (TTY)
• 1-866-415-8051 (TTY toll-free)

Available in English and Spanish

Monday through Friday
8:30 a.m. to 5:00 p.m. Eastern Time

Electroconvulsive Therapy And Other Brain Stimulation Therapies

If medications do not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an option to explore. There are a lot of outdated beliefs about ECT, but here are the facts:

• ECT can provide relief for people with severe depression who have not been able to feel better with other treatments.
• ECT can be an effective treatment for depression.
• ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually these side effects are short term, but sometimes they can linger. Talk to your doctor and make sure you understand the potential benefits and risks of the treatment.

Some people believe that ECT is painful or that you can feel the electrical impulses. This is not true. Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. He or she sleeps through the treatment and does not consciously feel the electrical impulses.

Within 1 hour after the treatment session, which takes only a few minutes, the patient is awake and alert.

Other more recently introduced types of brain stimulation therapies used to treat severe depression include repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS). In 2008, the FDA approved rTMS as a treatment for major depression for patients who have not responded to at least one antidepressant medication. In 2005, the FDA approved VNS for use in treating depression in certain circumstances—if the illness has lasted 2 years or more, if it is severe or recurrent, and if the depression has not eased after trying at least four other treatments. VNS is less commonly used, and more research is needed to test its effectiveness.

Quick Tip: Get the Latest Information

This information may have changed since the publication of this booklet, so please visit the NIMH website atwww.nimh.nih.gov to explore the latest research and the FDA website at www.fda.gov  for the most recently approved treatment options.

Beyond Treatment: Things You Can Do

If you have depression, you may feel exhausted, helpless, and hopeless. It may be extremely difficult to take any action to help yourself. But as you begin to recognize your depression and begin treatment, you will start to feel better. Here are other tips that may help you or a loved one during treatment:

• Try to be active and exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities, and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly “snap out of” your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.
• Continue to educate yourself about depression.

You are not alone.

Major depressive disorder is one of the most common mental disorders in the United States. You are not alone.

Sometimes living with depression can seem overwhelming, so build a support system for yourself. Your family and friends are a great place to start. Talk to trusted family members or friends to help them understand how you are feeling and that you are following your doctor’s recommendations to treat your depression.

In addition to your treatment, you could also join a support group. These are not psychotherapy groups, but some may find the added support helpful. At the meetings, people share experiences, feelings, information, and coping strategies for living with depression.

Remember: Always check with your doctor before taking any medical advice that you hear in your group.

You can find a support group through many professional, consumer, advocacy, and service-related organizations. On the NIMH website (www.nimh.nih.gov/outreach/partnership-program/index.shtml), there is a list of NIMH Outreach Partners. Some of these partners sponsor support groups for different mental disorders including depression. You can also find online support groups, but you need to be careful about which groups you join. Check and make sure the group is affiliated with a reputable health organization, moderated professionally, and maintains your anonymity.

If unsure where to start, talk to someone you trust who has experience in mental health—for example, a doctor, nurse, social worker, or religious counselor. Some health insurance providers may also have listings of hospitals offering support groups for depression.

Remember: Joining a support group does not replace your doctor or your treatment prescribed by your doctor. If a support group member makes a suggestion that you are interested in trying, talk to your doctor first. Do not assume what worked for the other person will work for you.

If You Think a Loved One May Have Depression

If you know someone who is depressed, it affects you too. The most important thing you can do is to help your friend or relative get a diagnosis and treatment. You may need to make an appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment or to seek different treatment options if no improvement occurs after 6 to 8 weeks.

To help your friend or relative:

• Offer emotional support, understanding, patience, and encouragement.
• Talk to him or her, and listen carefully.
• Never dismiss feelings, but point out realities and offer hope.
• Never ignore comments about suicide and report them to your loved one’s therapist or doctor.
• Invite your loved one out for walks, outings, and other activities. Keep trying if he or she declines, but don’t push him or her to take on too much too soon.
• Provide assistance in getting to doctors’ appointments.
• Remind your loved one that with time and treatment, the depression will lift.

Caring for someone with depression is not easy. Someone with depression may need constant support for a long period of time. Make sure you leave time for yourself and your own needs. If you feel you need additional support, there are support groups for caregivers too.

Helpful resources

NIMH has a variety of publications on depression available atwww.nimh.nih.gov/health/publications/depression-listing.shtml. If you need additional information and support, you may find the following resources to be helpful.

Centers for Medicare and Medicaid Services (CMS)

CMS is the Federal agency responsible for administering the Medicare, Medicaid, State Children’s Health Insurance (SCHIP), and several other programs that help people pay for health care. Visit www.cms.gov for more information.

Clinical Trials and You

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Treatments might be new drugs or new combinations of drugs, new surgical procedures or devices, or new ways to use existing treatments. To learn more about participating in a clinical trial, please visit www.nih.gov/health/clinicaltrials/index.htm .

Depression (PDQ^®)

PDQ^® (Physician Data Query) is the National Cancer Institute’s comprehensive cancer database. The PDQ cancer information summaries are peer-reviewed, evidence-based summaries on topics including adult and pediatric cancer treatment, supportive and palliative care, screening, prevention, genetics, and complementary and alternative medicine. Visit www.cancer.gov  (Search: Depression).

Locate Affordable Health Care in Your Area

Within the Federal Government, a bureau of the Health Resources and Services Administration provides a Health Center Database for a nationwide directory of clinics to obtain low or no-cost health care. Start your search at http://findahealthcenter.hrsa.gov/Search_HCC.aspx .

Mental Health Treatment Program Locator

The Substance Abuse and Mental Health Services Administration is pleased to provide this online resource for locating mental health treatment facilities and programs. The Mental Health Treatment Locator section of the Behavioral Health Treatment Services Locator lists facilities providing mental health services to persons with mental illness. Find a facility in your state at https://findtreatment.samhsa.gov/ .

National Alliance on Mental Illness (NAMI)

NAMI is the Nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. There are nearly 1,000 NAMI state organizations and NAMI affiliates across the country. Many NAMI affiliates offer an array of free support and education programs. Find your local NAMI at www.nami.org/Find-Your-Local-NAMI .

NIDA for Teens: Depression

NIDA for Teens website is a project of the National Institute on Drug Abuse (NIDA), National Institutes of Health. Created for middle and high school students and their teachers, this website provides accurate and timely information for use in and out of the classroom. Find information and discussions on depression athttp://teens.drugabuse.gov/  (Search: Depression).

NIHSeniorHealth: Depression

NIHSeniorHealth (www.NIHSeniorHealth.gov ) has added depression to its list of health topics of interest to older adults. This senior-friendly medical website is a joint effort of the National Institute on Aging and the National Library of Medicine, which are part of the National Institutes of Health (NIH). It is available athttp://nihseniorhealth.gov/depression/ .

St. John’s Wort and Depression

This fact sheet has information about St. John’s wort, a popular herb being used by the public today to treat mild depression. This publication includes information on the FDA’s role to monitor the use of this herb, how St. John’s wort works, how it is used to treat depression, and a drug interaction advisory. Read it athttps://nccih.nih.gov/health/stjohnswort/sjw-and-depression.htm .

Questions to Ask Your Doctor

Asking questions and providing information to your doctor and other care providers can improve your care. Talking with your doctor builds trust and leads to better results, quality, safety, and satisfaction. Visit the Agency for Healthcare Research and Quality website for tips at www.ahrq.gov/patients-consumers/index.html .

Reprints

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of NIMH as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
• NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of such information.
• NIMH requests that non-Federal organizations not alter our publications in ways that will jeopardize the integrity and “brand” when using the publication.
• Addition of non-Federal Government logos and website links may not have the appearance of NIMH endorsement of any specific commercial products or services, or medical treatments or services.
• Images used in publications are of models and are used for illustrative purposes only. Use of some images is restricted.

Do you go through intense moods?

Do you feel very happy and energized some days, and very sad and depressed on other days? Do these moods last for a week or more? Do your mood changes make it hard to sleep, stay focused, or go to work?

Some people with these symptoms have bipolar disorder, a serious mental illness. This brochure will give you more information.

What is bipolar disorder?

Bipolar disorder is a serious brain illness. It is also called manic-depressive illness or manic depression. People with bipolar disorder go through unusual mood changes. Sometimes they feel very happy and “up,” and are much more energetic and active than usual. This is called a manic episode. Sometimes people with bipolar disorder feel very sad and “down,” have low energy, and are much less active. This is called depression or a depressive episode.

Bipolar disorder is not the same as the normal ups and downs everyone goes through. The mood swings are more extreme than that and are accompanied by changes in sleep, energy level, and the ability to think clearly. Bipolar symptoms are so strong that they can damage relationships and make it hard to go to school or keep a job. They can also be dangerous. Some people with bipolar disorder try to hurt themselves or attempt suicide.

People with bipolar disorder can get treatment. With help, they can get better and lead successful lives.

Who develops bipolar disorder?

Anyone can develop bipolar disorder. It often starts in a person’s late teen or early adult years. But children and older adults can have bipolar disorder too. The illness usually lasts a lifetime.

Why does someone develop bipolar disorder?

Doctors do not know what causes bipolar disorder, but several things may contribute to the illness. Family genes may be one factor because bipolar disorder sometimes runs in families. However, it is important to know that just because someone in your family has bipolar disorder, it does not mean other members of the family will have it as well. Another factor that may lead to bipolar disorder is the brain structure or the brain function of the person with the disorder. Scientists are finding out more about the disorder by studying it. This research may help doctors do a better job of treating people. Also, this research may help doctors to predict whether a person will get bipolar disorder. One day, doctors may be able to prevent the illness in some people.

What are the symptoms of bipolar disorder?

Bipolar “mood episodes” include unusual mood changes along with unusual sleep habits, activity levels, thoughts, or behavior. People may have manic episodes, depressive episodes, or “mixed” episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that last a week or two or sometimes longer. During an episode, the symptoms last every day for most of the day.

Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels.

People having a manic episode may:

• Feel very “up” or “high”
• Feel “jumpy” or “wired”
• Have trouble sleeping
• Become more active than usual
• Talk really fast about a lot of different things
• Be agitated, irritable, or “touchy”
• Feel like their thoughts are going very fast
• Think they can do a lot of things at once
• Do risky things, like spend a lot of money or have reckless sex

People having a depressive episode may:

• Feel very “down” or sad
• Sleep too much or too little
• Feel like they can’t enjoy anything
• Feel worried and empty
• Have trouble concentrating
• Forget things a lot
• Eat too much or too little
• Feel tired or “slowed down”
• Have trouble sleeping
• Think about death or suicide

Can someone have bipolar disorder along with other problems?

Yes. Sometimes people having very strong mood episodes may have psychotic symptoms. Psychosis affects thoughts and emotions as well as a person’s ability to know what is real and what is not. People with mania and psychotic symptoms may believe they are rich and famous, or have special powers. People with depression and psychotic symptoms may believe they have committed a crime, they have lost all of their money, or that their lives are ruined in some other way.

Sometimes behavior problems go along with mood episodes. A person may drink too much or take drugs. Some people take a lot of risks, like spending too much money or having reckless sex. These problems can damage lives and hurt relationships. Some people with bipolar disorder have trouble keeping a job or doing well in school.

Is bipolar disorder easy to diagnose?

No. Some people have bipolar disorder for years before the illness is diagnosed. This is because bipolar symptoms may seem like several different problems. Family and friends may notice the symptoms but not realize they are part of a bigger problem. A doctor may think the person has a different illness, like schizophrenia or depression.

People with bipolar disorder often have other health problems as well. This may make it hard for doctors to recognize the bipolar disorder. Examples of other illnesses include substance abuse, anxiety disorders, thyroid disease, heart disease, and obesity.

How is bipolar disorder treated?

Right now, there is no cure for bipolar disorder, but treatment can help control symptoms. Most people can get help for mood changes and behavior problems. Steady, dependable treatment works better than treatment that starts and stops. Treatment options include:

1. Medication. There are several types of medication that can help. People respond to medications in different ways, so the type of medication depends on the patient. Sometimes a person needs to try different medications to see which works best.

Medications can cause side effects. Patients should always tell their doctors about these problems.Also, patients should not stop taking a medication without a doctor’s help. Stopping medication suddenly can be dangerous, and it can make bipolar symptoms worse.

2. Therapy. Different kinds of psychotherapy, or “talk” therapy, can help people with bipolar disorder. Therapy can help them change their behavior and manage their lives. It can also help patients get along better with family and friends. Sometimes therapy includes family members.

3. Other treatments. Some people do not get better with medication and therapy. These people may try electroconvulsive therapy, or ECT. This is sometimes called “shock” therapy. ECT provides a quick electric current that can sometimes correct problems in the brain.

Sometimes people take herbal and natural supplements, such as St. John’s wort or omega-3 fatty acids. Talk to your doctor before taking any supplement. Scientists aren’t sure how these products affect people with bipolar disorder. Some people may also need sleep medications during treatment.

Personal Story

James has bipolar disorder.

Here’s his story.

Four months ago, James found out he has bipolar disorder. He knows it’s a serious illness, but he was relieved when he found out. That’s because he had symptoms for years, but no one knew what was wrong. Now he’s getting treatment and feeling better.

James often felt really sad. As a kid, he skipped school or stayed in bed when he was down. At other times, he felt really happy. He talked fast and felt like he could do anything. James lived like this for a long time, but things changed last year. His job got very stressful. He felt like he was having more “up” and “down” times. His wife and friends wanted to know what was wrong. He told them to leave him alone and said everything was fine.

A few weeks later, James couldn’t get out of bed. He felt awful, and the bad feelings went on for days. Then, his wife took him to the family doctor, who sent James to a psychiatrist. He talked to this doctor about how he was feeling. Soon James could see that his ups and downs were serious. He was diagnosed with bipolar disorder, and he started treatment.

These days, James takes medicine and goes to talk therapy. Treatment was hard at first, and recovery took some time, but now he’s back at work. His mood changes are easier to handle, and he’s having fun again with his wife and friends.

Getting Help

If you’re not sure where to get help, call your family doctor. You can also check the phone book for mental health professionals. Hospital doctors can help in an emergency. Finally, the Substance Abuse and Mental Health Services Administration (SAMHSA) has an online tool to help you find mental health services in your area. You can find it here: https://findtreatment.samhsa.gov .

How can I help myself if I have bipolar disorder?

You can help yourself by getting treatment and sticking with it. Recovery takes time, and it’s not easy. But treatment is the best way to start feeling better. Here are some tips:

• Talk with your doctor about your treatment.
• Stay on your medication.
• Keep a routine for eating and sleeping.
• Make sure you get enough sleep.
• Learn to recognize your mood swings.
• Ask a friend or relative to help you stick with your treatment.
• Be patient with yourself. Improvement takes time.

How can I help someone I know with bipolar disorder?

Help your friend or relative see a doctor to get the right diagnosis and treatment. You may need to make the appointment and go to the doctor together. Here are some helpful things you can do:

• Be patient.
• Encourage your friend or relative to talk, and listen carefully.
• Be understanding about mood swings.
• Include your friend or relative in fun activities.
• Remind the person that getting better is possible with the right treatment.

I know someone who is in crisis. What do I do?

If you know someone who might hurt himself or herself, or if you’re thinking about hurting yourself, get help quickly. Here are some things you can do:

• Do not leave the person alone.
• Call your doctor.
• Call 911 or go to the emergency room.
• Call the National Suicide Prevention Lifeline, toll-free:
  1-800-273-TALK (8255). The TTY number is 1-800-799-4TTY (4889).

How does bipolar disorder affect friends and family?

When a friend or relative has bipolar disorder, it affects you too. Taking care of someone with bipolar disorder can be stressful. You have to cope with the mood swings and sometimes other problems, such as drinking too much. Sometimes the stress can strain your relationships with other people. Caregivers can miss work or lose free time.

If you are taking care of someone with bipolar disorder, take care of yourself too. Find someone you can talk to about your feelings. Talk with the doctor about support groups for caregivers. If you keep your stress level down, you will do a better job, and it might help your loved one stick to his or her treatment.