What is depression?
Depression is an illness that causes you to feel sad, to lose interest in activities that you've always enjoyed, to withdraw from others, and to have little energy. It's different from normal feelings of sadness, grief, or low energy. Depression can also cause people to feel hopeless about the future and even to think about suicide.
Many people, and sometimes their families, feel embarrassed or ashamed about having depression. Don't let these feelings stand in the way of getting treatment. Remember that depression is a common illness. Depression affects the young and old, men and women, all ethnic groups, and all professions.
If you think you may be depressed, tell your doctor. Treatment can help you enjoy life again. The sooner you get treatment, the sooner you will feel better.
What causes depression?
Depression is a disease. It's not caused by personal weakness and is not a character flaw. When you have depression, chemicals in your brain called neurotransmitters are out of balance.
Most experts believe a combination of family history (your genes) and stressful life events may cause depression. Life events can include:
- Childbirth, a death in the family, work, or relationships.
- Finding out you have a long-term health problem, such as arthritis, heart disease, or cancer.
- Health problems, such as anemia and an underactive thyroid gland (hypothyroidism). Treating the health problem can usually cure the depression.
Just because you have a family member with depression or have stressful life events doesn't mean you'll get depression.
You also may get depressed even if there is no reason you can think of.
What are the symptoms?
The symptoms of depression may be hard to notice at first. They vary among people, and you may confuse them with just feeling "off" or with another health problem.
The two most common symptoms of depression are:
- Feeling sad or hopeless nearly every day for at least 2 weeks.
- Losing interest in or not getting pleasure from most daily activities nearly every day for at least 2 weeks.
A serious symptom of depression is thinking about death or suicide. If you or someone you care about talks about this or feeling hopeless, get help right away.
You also may:
- Lose or gain weight. You also may feel like eating more or less than usual almost every day.
- Sleep too much or not enough almost every day.
- Feel restless and not be able to sit still, or you may sit quietly and feel that moving takes great effort. Others can easily see this behavior.
- Feel tired or as if you have no energy almost every day.
- Feel unworthy or guilty nearly every day. You may have low self-esteem and worry that people don't like you.
- Find it hard to focus, remember things, or make decisions nearly every day. You may feel anxious about things.
If you have some of these symptoms for at least 2 weeks, talk to your doctor. Treatment may be right for you.
If you think you may have depression, take a short quiz to check your symptoms:
"Antidepressants' Benefits May Be Exaggerated." "Antidepressants Under Scrutiny Over Efficacy." "End of the Prozac Nation?" In early 2008, a pair of studies questioning the track record of antidepressants spawned a rash of headlines like these and led depression patients to wonder if their antidepressants were doing any good.
The first salvo against antidepressants came from a study led by Erick Turner, MD, a psychiatrist at Oregon Health & Science University. After reviewing the entire mass of drug-company studies submitted to the FDA (where he once worked as a reviewer) in the approval process for 12 antidepressants, Dr. Turner and his fellow researchers reported that 94% of the studies with positive results were later published, while only 14% with negative or ambiguous results found their way into print.
The first salvo against antidepressants came from a study led by Erick Turner, MD, a psychiatrist at Oregon Health & Science University. After reviewing the entire mass of drug-company studies submitted to the FDA (where he once worked as a reviewer) in the approval process for 12 antidepressants, Dr. Turner and his fellow researchers reported that 94% of the studies with positive results were later published, while only 14% with negative or ambiguous results found their way into print.
This so-called "file-drawer effect" has made antidepressants appear more effective than they actually are, at least to physicians and the public. "There is a view that these drugs are effective all the time," Dr. Turner told The Wall Street Journal. When he would tell other doctors that antidepressants work only 40% to 50% of the time, they would protest, "What are you talking about? I have never seen a negative study."
The second study, led by Irving Kirsch, a professor of psychology at the University of Hull, in Britain, arrived at a similar conclusion. Kirsch found that when he factored in unpublished data, four widely prescribed antidepressants—all but one of which belonged to the popular class known as SSRIs (selective serotonin-reuptake inhibitors)—worked only marginally better in clinical trials than sugar pills. And even then, the only clinically significant efficacy was observed in severely depressed patients (who are less apt to respond to the placebo effect). "It is time for a change of emphasis to nondrug treatments and [to] reserve these drugs for very severely depressed patients," Kirsch said when the study was released.
In clinical practice, antidepressants work
In response to these studies and the ensuing publicity, many psychiatrists and other doctors were quick to vouch for the real-world benefits of antidepressants. "Most clinicians see them working extremely well for some people—and that’s where I am," says Michael Hirsch, MD, director of psychopharmacology at Boston’s Beth Israel Deaconess Medical Center and an instructor in psychiatry at Harvard Medical School. "I am convinced that they are not just placebos. In fact, when they work, they can have very profound effects." Dr. Hirsch’s caseload averages 300 patients; "a lot" are on SSRIs, he says.
Convincing evidence of the effectiveness of antidepressants that jibes with Dr. Hirsch’s firsthand experience has been reported in recent years. The most notable example was a federally funded study dubbed STAR*D, or Sequenced Treatment Alternatives to Relieve Depression, the largest (4,000 patients) and longest (seven years) analysis of antidepressants ever.
This study was designed to measure the overall rates of remissioninduced by a first-line antidepressant treatment, which was replaced, if necessary, by a second, third, and fourth antidepressant (for those whose symptoms persisted); it's a fair facsimile of how doctors deploy the drugs in practice. Two-thirds of the people who stuck with the study saw their symptoms go into remission, although only 37% and 31% got that result on their first and second treatment, respectively. And more than a third of those who achieved remission relapsed within a year. While it may have been somewhat inflated by the carefully monitored treatment given to participants (compared to an occasional visit with a primary care physician, for instance), a remission rate of 67% doesn’t exactly spell the "End of Prozac Nation."
The second study, led by Irving Kirsch, a professor of psychology at the University of Hull, in Britain, arrived at a similar conclusion. Kirsch found that when he factored in unpublished data, four widely prescribed antidepressants—all but one of which belonged to the popular class known as SSRIs (selective serotonin-reuptake inhibitors)—worked only marginally better in clinical trials than sugar pills. And even then, the only clinically significant efficacy was observed in severely depressed patients (who are less apt to respond to the placebo effect). "It is time for a change of emphasis to nondrug treatments and [to] reserve these drugs for very severely depressed patients," Kirsch said when the study was released.
In clinical practice, antidepressants work
In response to these studies and the ensuing publicity, many psychiatrists and other doctors were quick to vouch for the real-world benefits of antidepressants. "Most clinicians see them working extremely well for some people—and that’s where I am," says Michael Hirsch, MD, director of psychopharmacology at Boston’s Beth Israel Deaconess Medical Center and an instructor in psychiatry at Harvard Medical School. "I am convinced that they are not just placebos. In fact, when they work, they can have very profound effects." Dr. Hirsch’s caseload averages 300 patients; "a lot" are on SSRIs, he says.
Convincing evidence of the effectiveness of antidepressants that jibes with Dr. Hirsch’s firsthand experience has been reported in recent years. The most notable example was a federally funded study dubbed STAR*D, or Sequenced Treatment Alternatives to Relieve Depression, the largest (4,000 patients) and longest (seven years) analysis of antidepressants ever.
This study was designed to measure the overall rates of remissioninduced by a first-line antidepressant treatment, which was replaced, if necessary, by a second, third, and fourth antidepressant (for those whose symptoms persisted); it's a fair facsimile of how doctors deploy the drugs in practice. Two-thirds of the people who stuck with the study saw their symptoms go into remission, although only 37% and 31% got that result on their first and second treatment, respectively. And more than a third of those who achieved remission relapsed within a year. While it may have been somewhat inflated by the carefully monitored treatment given to participants (compared to an occasional visit with a primary care physician, for instance), a remission rate of 67% doesn’t exactly spell the "End of Prozac Nation."
Antidepressant backlash?
To some extent, antidepressants may be a victim of their own success. Prozac, the first of the SSRIs, was approved by the FDA in 1987, and within three years, nearly 4.5 million Americans had tried it. By 2002, the number of Americans who had received a prescription for an SSRI had soared to 67.5 million by some estimates, and more than 7.5 million had become long-term users. By 2005, the number of antidepressant prescriptions filled in the United States was up to 170 million.
As these statistics suggest, over the past two decades a good portion of the population has been diagnosed with depression or a related condition and treated with antidepressants. Such eye-popping numbers, not to mention Big Pharma’s massive marketing effort, have inevitably raised allegations of overprescribing. SSRIs are being prescribed for a wide range of medical conditions far beyond depression, from social anxiety to premenstrual syndrome to compulsions of all kinds—shopping, eating, gambling, and sex. Children are taking antidepressants for attention deficit hyperactivity disorder (ADHD), as are the elderly for dementia. Even dogs are having the pills forced down their throats.
To some extent, antidepressants may be a victim of their own success. Prozac, the first of the SSRIs, was approved by the FDA in 1987, and within three years, nearly 4.5 million Americans had tried it. By 2002, the number of Americans who had received a prescription for an SSRI had soared to 67.5 million by some estimates, and more than 7.5 million had become long-term users. By 2005, the number of antidepressant prescriptions filled in the United States was up to 170 million.
As these statistics suggest, over the past two decades a good portion of the population has been diagnosed with depression or a related condition and treated with antidepressants. Such eye-popping numbers, not to mention Big Pharma’s massive marketing effort, have inevitably raised allegations of overprescribing. SSRIs are being prescribed for a wide range of medical conditions far beyond depression, from social anxiety to premenstrual syndrome to compulsions of all kinds—shopping, eating, gambling, and sex. Children are taking antidepressants for attention deficit hyperactivity disorder (ADHD), as are the elderly for dementia. Even dogs are having the pills forced down their throats.
Share Your Thoughts
Are your antidepressants working?
As the media and blogosphere clamor that SSRIs are ineffective, overprescribed, and even dangerous (concern that the drugs may lead to an increase in suicidality among young people prompted the FDA to add a "black box" warning to all antidepressants), the people who could benefit from the drugs but don’t access them are often overlooked.
The National Institute of Mental Health (NIMH) estimates that as many as two-thirds of Americans with depression don’t get appropriate treatment, and as Kirsch’s study illustrated, antidepressants have shown to be most effective in those who are most depressed.
"These drugs are both overprescribed for people who don’t need them and underprescribed for people who do need them," says Dr. Hirsch.
The National Institute of Mental Health (NIMH) estimates that as many as two-thirds of Americans with depression don’t get appropriate treatment, and as Kirsch’s study illustrated, antidepressants have shown to be most effective in those who are most depressed.
"These drugs are both overprescribed for people who don’t need them and underprescribed for people who do need them," says Dr. Hirsch.
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