Understanding depression

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What is depression?
What are the symptoms of depression?
What causes depression?
What can I do to help myself?
What treatments are available?
What if my depression is worse, or won't go away?
What can friends or relatives do to help?
Useful organisations
Further reading

"I felt detached from the world around me. All emotions – love, affection, anger – were gone. Actually, I can't say I had no emotions, I did, but they all seemed desperately negative. Most involved fear. Fear that I would never escape the condition."

"I was so scared of being alone with my thoughts. At night, everything seemed so bleak. I couldn't concentrate on anything; I couldn't read or watch TV. I couldn't relax or unwind. Sleep seemed impossible – so many thoughts were racing through my mind. I would spend hours fantasising about ways of killing myself."

"Everything to do with everyday life seemed like such hard work. I simply didn't have the energy to go to work, to see friends, to shop, cook or clean. It all seemed pointless! What was the point in eating, when I didn't even want to be alive?"

This booklet describes the symptoms of depression and the different kinds of treatment available. It suggests ways that people can help themselves, and what family and friends can do. It also tells you where to find further advice and information.

If you are depressed, you may feel that nothing can help. But this is untrue. Deciding to do something is the most important step you can take. Most people recover from bouts of depression, and some even look back on it as a useful experience, which forced them to take stock of their lives and make changes in their lifestyle.

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What is depression?

We often use the expression "I'm feeling depressed" when we're feeling sad or miserable about life. Usually, these feelings pass in due course. But, if the feelings are interfering with your life and don't go away after a couple of weeks, or if they come back, over and over again, for a few days at a time, it could be a sign that you're depressed in the medical sense of the term.

In its mildest form, depression can mean just being in low spirits. It doesn’t stop you leading your normal life, but makes everything harder to do and seem less worthwhile. At its most severe, major depression (clinical depression) can be life-threatening, because it can make people suicidal or simply give up the will to live.

There are also various specific forms of depression:

Seasonal affective disorder (SAD)
If you usually become depressed only during the autumn and winter, it could be due to not getting enough daylight. You may benefit from spending time sitting in front of a special light box. (For further information, see the Mind booklet Understanding seasonal affective disorder.

Postnatal depression
Many mothers have ‘the baby blues’ soon after the birth of their baby, but it usually passes after a few days. Postnatal depression is a more serious problem and can appear any time between two weeks and two years after the birth. (For further information, see Mind’s booklet Understanding postnatal depression.)

Bipolar disorder (manic depression)
Some people have mood swings, when periods of depression alternate with periods of mania. When manic, they are in a state of high excitement, and may plan and may try to execute grandiose schemes and ideas. (See Mind's booklet Understanding bipolar disorder (manic depression).)

At least one person in every six becomes depressed in the course of their lives. One in 20 is clinically depressed. Figures suggest that more women become depressed, but men may find it harder to admit to or talk about. All age groups can be affected, and it’s important to take symptoms seriously and not to dismiss them as an inevitable part of growing up or growing old. By recognising and treating the symptoms, and getting help, it’s possible to overcome depression, and prevent it coming back.

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What are the symptoms of depression?

Depression shows up in many different ways. People don't always realise what's going on, because their problems seem to be physical, not mental. They tell themselves they're simply under the weather or feeling tired. But, if you tick off five or more of the following symptoms, it's likely you're depressed.

• being restless and agitated
• waking up early, having difficulty sleeping, or sleeping more
• feeling tired and lacking energy; doing less and less
• using more tobacco, alcohol or other drugs than usual
• not eating properly and losing or putting on weight
• crying a lot
• difficulty remembering things
• physical aches and pains with no physical cause
• feeling low-spirited for much of the time, every day
• being unusually irritable or impatient
• getting no pleasure out of life or what you usually enjoy
• losing interest in your sex life
• finding it hard to concentrate or make decisions
• blaming yourself and feeling unnecessarily guilty about things
• lacking self-confidence and self-esteem
• being preoccupied with negative thoughts
• feeling numb, empty and despairing
• feeling helpless
• distancing yourself from others; not asking for support
• taking a bleak, pessimistic view of the future
• experiencing a sense of unreality
• self-harming (by cutting yourself, for example)
• thinking about suicide.

Anxiety
People who are depressed are often very anxious. It's not clear whether the anxiety leads into the depression or whether the depression causes the anxiety. A person feeling anxious may have a mind full of busy, repetitive thoughts, which make it hard to concentrate, relax, or sleep. They may have physical symptoms, such as headaches, aching muscles, sweating and dizziness. It may cause physical exhaustion and general ill health. (See Further reading.)

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What causes depression?

There's no one cause of depression; it varies very much from person to person and can happen for a combination of factors. Although depression, as such, doesn't seem to be inherited through the genes (with the possible exception of manic depression), some of us are more prone to depression than others. This could be because of the way we're made, or because of our experiences or family background.

Past experiences can have a profound effect on how we feel about ourselves in the present, and if those feelings are very negative, they can be the start of a downward spiral. In many cases, the first time someone becomes depressed, it's triggered by an unwelcome or traumatic event, such as being sacked, divorced, physically attacked or raped.

Depression is seen by some experts as a form of unfinished mourning. Often events or experiences that trigger depression can also be seen as a loss of some kind. It could be following the actual death of someone close, a major life change (such as moving house or changing jobs) or simply moving from one phase of life into another, as we reach retirement or our childen leave home. It’s not just the negative experience that causes the depression, but how we deal with it. If the feelings provoked are not expressed or explored at the time, they fester and contribute towards depression. It's important to acknowledge and grieve over what we have lost in order to be able to move on successfully.

Depression may also be caused by an underactive thyroid. The thyroid gland controls metabolic rate and, if it is not working properly, can cause you to experience various symptoms. If it is underactive, you will feel sluggish and lethargic, may put on weight, and feel depressed. If it is overactive, you may feel very speeded up, lose weight and have symptoms similar to mania. It is important to have a thyroid function test (a simple blood test) to make sure that this is not the cause of your depression, especially if you cannot account for it in other ways, such as recent life events. If an underactive thyroid is diagnosed, it can be treated successfully with appropriate medication. (See Useful websites.)

Anecdotal evidence suggests that occasionally people become very depressed in response to certain foods. Such a reaction is very individual, and people are often not aware of the particular food substance or drink that is causing the problem. But if you suddenly feel depressed for no apparent reason, it may be worth considering whether you have eaten or drunk something new, and whether this might have caused your sudden change of mood. If this is the cause, your mood should lift very quickly, so long as you don’t consume any more of the particular item. (See The Mind guide to food and mood.)

Poor diet, lack of physical fitness, and illnesses, such as flu, can all leave us feeling depressed. Frequent use of some recreational drugs can also play a part. (For more information, see Understanding the psychological effects of street drugs.)

It's clear that people who are depressed show changes to the chemical messengers (called neurotransmitters) in the brain. It's less clear whether this is a cause or a result of the depression.

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What can I do to help myself?

Depression has one major characteristic that you need to be aware of when thinking about what you can do to defeat it. It can feed on itself. In other words, you get depressed and then you get more depressed about being depressed. Negative thoughts become automatic and are difficult for you to challenge. Being in a state of depression can then, itself, become a bigger problem than the difficulties that caused it in the first place. You need to break the hold that the depression has on you.

An important thing to remember is that there are no instant solutions to problems in life. Solving problems involves time, energy and work. When you are feeling depressed, you may well not be feeling energetic or motivated to work. But if you are able to take an active part in your treatment, it should help your situation.

Fighting negative attitudes
Try to recognise the pattern of negative thinking when you are doing it, and replace it with a more constructive activity. Look for things to do that occupy your mind.

Activity is good for the mind
Although you may not feel like it, it’s very therapeutic to take part in physical activities, for 20 minutes a day. Playing sports, running, dancing, cycling, and even brisk walking can stimulate chemicals in the brain called endorphins, which can help you to feel better. (See Mind guide to physical activity.)

Caring for yourself
You need to do things that will improve the way you feel about yourself. Allow yourself positive experiences and treats that reinforce the idea that you deserve good things. Pay attention to your personal appearance. Set yourself goals that you can achieve and that will give you a sense of satisfaction.

Look after yourself by eating healthily. Oily fish, in particular, may help alleviate depression. Don’t abuse your body with tobacco, alcohol or other drugs, which make it worse.

Alternative and complementary therapies
Practitioners of complementary and alternative medicine concern themselves with the person as a whole, and don't merely treat their symptoms. They can take more time with you than a GP can.

Practitioners may offer treatments such as acupuncture, massage, homeopathy and herbal medicine that many people with depression have found helpful. St John's Wort is one of the herbal remedies that have become very popular, and may help to lift your mood. But if you are already taking other medication, it may not be safe to combine them. Consult your pharmacist or GP for more information.

Self-help groups
It can be a great relief to meet and share experiences with other people who are going through the same thing you are. It can break down feelings of isolation and, at the same time, show you how other people have coped. Finding that you can support others can help you, too.

These groups are often led by people who have overcome depression themselves. For help in locating local self-help groups, talk to your GP and consult the Useful organisations.

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What treatments are available?

At a time when you may well find making decisions difficult, it can also seem like an added burden to try and choose between a range of treatment options.

What is actually available to you may depend very much on where you live. For example, talking treatments, such as counselling and psychotherapy, are more readily available in London and the South-East than they are in rural areas of northern England. You should be able to choose freely among a range of treatment options, but, in practice, most people attending GP surgeries are offered antidepressants as the first treatment choice. Don't be afraid to ask your GP about the treatments offered and what the alternatives are.

The National Institute for Health and Clinical Excellence (NICE) published guidelines on the treatment of depression, in December 2004. These suggest that, for mild depression, antidepressants are not appropriate because the risk of side effects outweighs the benefits. Suggested treatments include watchful waiting – a recognition of the fact that depression often goes away without treatment – guided self-help, short-term talking treatments such as cognitive behaviour therapy (CBT), and exercise programmes. For more severe depression antidepressants are appropriate, and selective serotonin reuptake inhibitors (SSRI)s are suggested because their side effects are usually better tolerated than those of the alternative types of antidepressants. However, combining a psychological treatment with medication maybe the most effective course for severe depression.

Antidepressants
Antidepressant drugs are the most common medical treatment for depression. They work on chemical messengers in the brain to lift your mood. They can’t cure depression, but they can alleviate the symptoms so that you may feel able to take action to deal with the depression yourself. It often takes between two to four weeks before the drugs take effect. The usual recommendation is that you stay on them for six months in order to prevent a recurrence. They don’t work for everyone.

Antidepressants frequently cause unpleasant side effects, which are worse to begin with. Some can be dangerous when used with other drugs. Of the various different types available, SSRIs are usually the preferred first choice because, although they have as many listed side effects as older drugs, they are usually better tolerated. Others include tricyclic antidepressants and MAOIs (monoamine oxidase inhibitors). Whichever type of antidepressant you take, you may experience withdrawal symptoms when you stop taking them, especially if you have been taking them for some time. Because of this you should withdraw slowly, reducing the dose in stages over a period of weeks. (See Making sense of coming off psychiatric drugs and Making sense of antidepressants.)

Psychological treatments
Your GP may offer you one of the following psychological treatments. The choice will depend on what's available, your own preferences, how severe your depression is and other factors:

• Five or six sessions of problem-solving therapy can help people break down their problems into manageable portions and provides strategies for coping with them.
• Cognitive behaviour therapy (CBT) helps to identify and change negative thoughts and feelings affecting behaviour and may last up to 12 months. Computerised CBT (CCBT) is now available and can be used in addition to or instead of sessions with a therapist. It is not suitable for someone with severe symptoms though, and NICE recommend individuals are assessed before using one of the programmes.
• Guided self-help delivers a six to eight week therapy programme through self-help books, under the guidance of a healthcare professional.
• Interpersonal psychotherapy (IPT) focuses on relationships. Therapy can continue for 6 to 12 months.
• Counselling can be short- or long-term. It involves talking with someone who is trained to listen with empathy and acceptance. This allows you to express your feelings and find your own solutions to your problems.

Psychotherapy is not usually available on the NHS. It is more frequent and intensive than counselling, and goes more deeply into childhood experience and significant relationships. Most psychotherapists work in private practice. (For lists of qualified and regulated therapists, see Useful organisations. For more information, see Further reading.)

Painful experiences are hard to talk about, but healthcare professionals understand this. Be as frank as possible, so that people can offer you the best help. Don't be afraid to ask questions about your condition.

Befriending schemes
Your GP may put you in touch with a local befriending scheme with trained volunteers who could visit, weekly, to give you practical advice, support and a sympathetic ear.

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What if my depression is worse, or won't go away?

Your GP may refer you to a specialist mental heath professional, such as a psychiatrist, psychologist or mental health nurse, who can review your treatment so far. They may suggest a different medication, or a combination of drugs or of treatments. Medication combined with psychological treatments seems to be the most effective way of dealing with severe or long-lasting depression.

You may need support to live independently, in the community. The Care Programme Approach aims to ensure that you are assessed and that the right services are provided for you by social services and the health authorities. You should be allocated a care coordinator to be responsible for this. You should be given an advance statement, which is a written treatment plan that also specifies which treatments you would prefer not to have.

Community Mental Health Teams (CMHTs) are often the most easily accessible service for people with mental health problems. They can provide support for people living in their own homes. The CMHTs are multi-disciplinary teams, which may include a psychiatrist, community psychiatric nurses (CPNs), social workers and support workers, among others.

Hospital admission
If you are severely depressed, you may need the shelter and protection offered by the psychiatric ward of a hospital. It also gives a psychiatrist the opportunity to monitor the effects of different treatments. Hospital can provide a safe and supportive environment if you are in a state of distress, and it may be comforting to have other people around you and to know that you are being cared for.

However, it can be distressing to be on a ward where you have little privacy, where you have to fit in to routines that may not suit you, and where you may be upset by the behaviour of other patients. Generally, doctors want to keep patients out of hospital, but some patients are compulsorily detained, if it's thought to be necessary, for their own health or safety or the protection of others. (See Mind rights guide 1: civil admission to hospital .)

Crisis resolution services
These are teams of doctors and nurses who provide intensive support, which will enable you to stay at home if you're in crisis, rather than going into hospital. This service is not yet available countrywide.

Electroconvulsive therapy (ECT)
This is a controversial treatment, usually offered only when people who are severely depressed haven't responded to drug treatment. It involves passing an electric current through the brain, while you are under general anaesthetic. The resulting convulsion may alleviate the depression, but can also have severe side effects, including memory loss. (For further information, see Mind’s booklet Making sense of electroconvulsive therapy [ECT].)

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What can friends or relatives do to help?

The very nature of depression, which brings a sense of hopelessness, helplessness and worthlessness, can prevent someone who's depressed from seeking help. They often withdraw from friends and relatives around them, rather than asking for help or support. However, this is a time when they need your help and support most. Perhaps the most important thing that you can do is to encourage your friend or relative to seek appropriate treatment.

Try not to blame them for being depressed, or tell them to 'pull themselves together'. They are probably already blaming themselves, and criticism is likely to make them feel even more depressed. Praise is much more effective than criticism. You can reassure them that it is possible to do something to improve their situation, but you need to do so in a caring and sympathetic way.

People who are depressed need someone who cares for them. You can show that you care by listening, sympathetically, by being affectionate, by appreciating the person, or simply by spending time with them. You can help by encouraging them to talk about how they are feeling and getting them to work out what they can do, or what they need to change, in order to deal with their depression.

If the person you are supporting is severely depressed, you may be faced with some hard decisions about how much to do on their behalf. If, for example, they are not looking after their physical needs, should you take over and do the shopping, cooking and cleaning for them, if you are able to? Or should you try and encourage them to do it? There are no easy answers to this situation. It will help if you can find someone with whom you can discuss these and other issues.

Supporting a friend or relative who is depressed can be an opportunity to build a closer and more satisfying relationship. However, it can also be hard work and frustrating, at times. Unless you pay attention to your own needs, it can make you feel depressed, too. Try and share the responsibility with as many people as possible, and find people to whom you can express your frustrations. There may be a local support group of others in your situation. You could also talk to your GP or another healthcare professional about getting help for yourself and your family. (See Useful organisations and How to cope as a carer.)

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Useful organisations

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484
web: www.babcp.com
To find a behavioural therapist

British Association for Counselling and Psychotherapy (BACP)
tel. 01455 883 300 (general enquiries)
tel. 0870 443 5220 (to find a therapist)
web: www.bacp.co.uk
See website or phone for details of local practitioners

British Psychoanalytic Council (BCP)
tel. 020 7267 3626
web: www.bcp.org.uk 
A linking body of psychoanalytical psychotherapist societies

Carers UK
helpline: 0808 808 7777
web: www.carersuk.org.uk 
Information and advice on all aspects of caring

Depression Alliance
tel. 0845 123 2320
web: www.depressionalliance.org 
Provides information, support and understanding

The Institute for Complementary Medicine (ICM)
tel. 020 7231 5855
web: www.i-c-m.org.uk 
Provides a list of professional, competent practitioners

MDF The Bipolar Organisation
tel. 08456 340 540
web: www.mdf.org.uk 
Helps people affected by manic depression

Rethink
advice line: 0845 456 0455
web: www.rethink.org 
Helps those affected by severe mental illness

Samaritans
Chris, PO Box 9090, Sterling FK8 2SA
helpline: 08457 90 90 90
email: jo@samaritans.org  
web: www.samaritans.org 
24-hour telephone helpline

Useful websites

www.foodforthebrain.org/depression

www.depressionuk.org 
A self-help organisation made up of individuals and local groups

www.thyromind.info 
Website raising awareness of thyroid disease as a possible cause of mental distress

www.nice.org.uk 
National Institute for Health and Clinical Excellence
Provides guidelines on treatments and on caring for people with depression

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Further reading

Climbing out of depression S. Atkinson (Lion Publishing 1993)
Coping with anxiety and depression S. Trickett (Sheldon 1997)
Depression in later life J.Manthorpe & S.Iliffe (Jessica Kingsley 2005)
Depression: the way out of your prison (3rd ed) D. Rowe (Routledge 2003)
How to cope as a carer (Mind 2006)
How to cope with suicidal feelings (Mind 2008)
How to help someone who is suicidal (Mind 2004)
Making sense of antidepressants (Mind 2008)
Making sense of cognitive behaviour therapy (Mind 2007)
Making sense of coming off psychiatric drugs (Mind 2005)
Making sense of counselling (Mind 2008)
Making sense of electroconvulsive therapy [ECT] (Mind 2008)
Making sense of psychotherapy and psychoanalysis (Mind 2004)
The Mind guide to food and mood (Mind 2006)
Mind guide to physical activity (Mind 2006)
Overcoming depression Dr W. Dryden, S. Opie (Sheldon Press 2003)
Overcoming depression: a self-help guide using cognitive behavioural techniques P. Gilbert (Constable 2000)
Understanding anxiety (Mind 2008)
Understanding bereavement (Mind 2008)
Understanding bipolar disorder [manic depression] (Mind 2006)
Understanding postnatal depression (Mind 2008)
Understanding seasonal affective disorder (Mind 2007)
Understanding the psychological effects of street drugs (Mind 2007)
Understanding talking treatments (Mind 2005)
When someone you love has depression B. Baker (Sheldon Press 2003)

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This booklet was written by George Stewart and revised by Katherine Darton
First published by Mind 1989. Revised edition © Mind 2008
ISBN 978-1-903567-32-6
No reproduction without permission