Depression - Symptoms, diagnosis, treatment and self-help

According to World Health Organisation (WHO) estimates, more than 350 million people around the world suffer from depression. In Austria, between 10-25% of people experience depression at least once during their life. Precise figures are hard to come by – not all cases of depression are identified and treated as such. Read on to learn about the signs and symptoms of depression, how low mood differs from depression, and the methods used to treat depression today.

Symptoms of depression

In psychiatry, depression is classified as what is termed an affective disorder. Sometimes referred to as mood disorders, affective disorders are a set of psychiatric disorders that are characterised by a clinically relevant change in mood, among other aspects. Depression is a psychiatric illness associated with a lack of drive, gloomy mood, a lack of interest and enjoyment, a limited sense of pleasure and a general lack of energy. Compared to people not suffering from depression, people with depression experience these symptoms far more acutely and for longer periods. They also find it harder to motivate themselves than people who do not have depression. What’s more, depression can be associated with a range of physical complaints, such as headaches, back pain, constipation, circulatory disorders and a feeling of tightness in the chest. People with depression sometimes find they no longer take pleasure in activities they would usually enjoy or experience changes in their appetite and, as a result, their weight.

Causes of depression

The potential causes of depression are just as diverse as the symptoms that people with the condition might experience. All kinds of difficult situations in life can trigger depression, including:

Prolonged or drawn-out conflict, either at work or at home
Long-term stress or exhaustion
Serious physical conditions
Experiences of loss, such as a break-up, divorce or the death of a loved one
Relocating and feeling out of place
Escaping from something
Losing a job
Traumatic childhood events (such as physical and/or sexual abuse)

Depression can also be caused by physical conditions. Such cases are referred to as organic depression. For instance, hypothyroidism – in which a person’s thyroid hormone levels are below normal – can lead to a depression-like state. To take another example, a tumour in the frontal lobe can exert pressure on the structures in the front of the brain that work to regulate a person’s mood. Although research into the causes and triggers of depression continues to this day, we do know that the brain activity of a person with depression is different from someone not suffering from the disorder. Depression can alter the way nerve cells function in certain parts of the brain and can also cause changes in the activity of the neurotransmitters serotonin and noradrenaline. Neurotransmitters are also known as carrier substances in the brain and work to transmit information between nerve cells. In simple terms, if a person is depressed, the signal-carrying substances in their brain are out of balance. What’s more, a person has an elevated risk of depression if a blood relative also suffers from depression or has done in the past.

Difference between depression and low mood

Conflicts at work, tension in a relationship, a break-up, disputes, financial difficulties, an accident or the loss of a loved one can cause anyone to feel down. Feelings of exhaustion, inner anxiety, sadness, dejection and drabness are entirely normal: everyone experiences these feelings, some people more than others. In a medical sense, however, low mood is considered distinct from depression and is often connected to a difficult event and/or stressful phase in life. Once the stress and pain recedes, a person’s mood tends to improve as well.

Definition of depression

According to ICD-10 (the 10th edition of International Statistical Classification of Diseases and Related Health Problems, issued by the WHO) the inclusion criteria for a depressive episode are met if a person suffers from at least two of the following three symptoms for a period of at least two weeks:

A low mood to an extent that is clearly unusual for the person in question, lasting for most of the day, almost every day, and generally unresponsive to circumstances
Loss of interest or pleasure in activities that would normally have been enjoyable
Reduced energy and marked tiredness after little effort

In addition, the person must present with at least one of the following symptoms:

Loss of self-confidence and sense of self-esteem
Unfounded feelings of self-blame or pronounced, unreasonable feelings of guilt
Recurrent thoughts about death or suicide
Reduced capacity to think or concentrate, hesitancy or indecisiveness
Abnormal psychomotor agitation (restlessness) or retardation
Sleep disturbances of all kinds
Loss of appetite – or increased appetite – with corresponding weight change

Most people might consider the line between low mood a depressive episode to be somewhat fluid. An experienced doctor, however, can tell the difference.

Classification and forms of depression

Depression is classified into three levels of severity:

Mild depression: In total, the person presents with at least three of the symptoms listed above, two of which are from the first category (low mood, loss of interest and enjoyment, reduced energy). While the patient feels unwell and seeks medical help, they are able to continue with most professional and personal activities despite their distress – provided these tasks are based in routine.
Moderate depression: In total, the person presents with at least six of the symptoms listed above, two of which are from the first category. They are unable to carry out professional or personal tasks, or can only do so from time to time.
Severe depression: In total, the person presents with at least eight of the symptoms listed above, including all three from the first category. A person experiencing a severe depressive episode without psychotic symptoms needs constant care and support. A depressive episode with psychotic symptoms might include manic thoughts, absurd feelings of guilt and/or feelings of fear about illness.

A distinction is also drawn between different types of depression. Depending on the severity, causes and presenting symptoms, depression is divided into the following types:

Unipolar depression: Unipolar depression is the most common form of depression. It develops very slowly; the person affected might only start to display symptoms after a few days, weeks or even months. In many cases, these symptoms also disappear of their own accord.
Bipolar depression: Alternating between dulled (depressive) mood and euphoria
Postnatal depression: The definition of postnatal depression states that it occurs to a person in the period between giving birth and their child’s first birthday. Women who have previously suffered from a form of depression have an elevated risk of being affected by postnatal depression.
Seasonal affected disorder: Seasonal affective disorders (SAD) is one of the less common forms of depression. As its name suggests, it is triggered by a particular season (e.g. winter depression)

Depending on the condition’s progression and the success of the therapies tried, it is also possible to classify depression further – as either a depressive episode (which might occur only once or several times) or chronic depression (when the symptoms persist for longer than two years). When a person fully regains their health, this is known as remission. In the event that a person’s symptoms markedly diminish but do not disappear completely, this is known as incomplete remission.

Winter depression

Winter depression occurs during the cold, dark part of the year. It affects four times as many women as it does men and is particularly common in Scandinavian and Central European countries. Winter depression is rare in southern countries. The causes of winter depression include the lack of natural daylight and reduced light intensity in the winter months, as well as the low temperatures. The body reacts to the lack of daylight by secreting increased amounts of melatonin, a hormone responsible for regulating our sleep pattern. As a result, we become tired more easily and our mood worsens. Typical symptoms of winter depression include an increased need for sleep, tiredness in the morning, a lack of drive and energy, a sense of imbalance and a subdued mood. In addition, the brain of a person with winter depression lacks serotonin (a hormone which helps to regulate our sleep pattern, body temperature, libido and emotional state) which means that people with the condition also experience an intensified craving for sweet treats, as sugar helps the brain to compensate for the serotonin imbalance.

Diagnosing depression

Many people avoid visiting their doctor or hide their symptoms due to an unwarranted sense of shame. Yet, a consultation with a doctor can help to identify the potential causes of changes in a person’s mood – and start a suitable course of treatment. Either a trained doctor or a psychiatrist will diagnose the disorder, primarily based on an in-depth consultation between the patient and doctor. In some cases, a blood test may be taken for analysis and a computer tomography (CT) scan carried out. This is to identify the cause of the depression and exclude any physical changes, such as a vitamin B12 deficiency, hormonal fluctuations or a low blood sugar level.

Treating depression

On the basis of the doctor-patient consultation and the results of any tests and scans, the physician can then draw up a suitable treatment plan. Depression can be treated both using medication and through psychotherapy. In many cases, a combination of the two proves particularly effective. The important thing to remember is that any therapy will take time: even with the perfect treatment plan, depression will not simply disappear overnight.

Antidepressants

Medications prescribed to treat depression are known as antidepressants. These antidepressants work by intervening in the various neurotransmitter systems in the patient’s brain and compensating for the neurotransmitter imbalance. A wide variety of antidepressants are available today; modern medications are far more targeted than antidepressants used in the past (such as so-called tricyclic and tetracyclic antidepressants) and also have fewer side effects. Today, the most commonly prescribed medications to treat depression include: selective serotonin reuptake inhibitors (or SSRIs, which block molecules that lead to the reabsorption of serotonin); serotonin–norepinephrine reuptake inhibitors (or SNRIs, which prevent the reabsorption of norepinephrine and serotonin in the brain), and norepinephrine–dopamine reuptake inhibitors (or NDRIs, which prevent the reuptake of norepinephrine and dopamine by the brain’s nerve cells). The active ingredients in modern antidepressants include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, duloxetine, milnacipran, venlafaxine, bupropion und reboxetine. Depending on the antidepressant prescribed, it can take on average eight days to three weeks for a person’s mood to improve. If medication fails to achieve the desired effect, the doctor might alter the patient’s dosage or prescribe a different antidepressant to treat the depression.

Psychotherapy

While medication can help to restore balance between neurotransmitters in a person’s brain, they cannot help to improve a person’s life situation and tackle the cause at its root. In psychotherapy, people suffering from depression can learn how to deal with (inner) conflicts and emotions more effectively, how to process break-ups more healthily and how to resolve interpersonal conflicts. If the cause of a person’s low mood is unknown, sessions with a psychotherapist can help to identify the underlying issues. There are many different types of therapy. Psychodynamic therapy, for instance, is used to work through deep-lying problems – which might have their roots in a person’s childhood – in a gradual process accompanied by a therapist. In behavioural therapy, on the other hand, the psychotherapist supports their patient to develop new behavioural strategies and move away from negative behaviours and thought patterns.

A good relationship between the psychotherapist and the patient is particularly important if the therapy is to be successful. It is crucial that an honest, trusting relationship develops so that both parties can discuss all problems and issues without reservations during the therapy. In addition to medication and psychotherapy, there are also other potential treatments; these include magnetic stimulation, kinesitherapy (also known as movement therapy), electroconvulsive therapy and light therapy. The latter is primarily used as a treatment for winter depression. In light therapy, the patient sits in front of a light device with six to eight lamps which emit fluorescent light (without harmful UV rays). The intensity of the emitted light is comparable to sunlight on a bright spring day and has a positive influence on certain structures in the brain. The recommended daily duration of light therapy ranges from half an hour to four hours You should always discuss such treatments with a doctor before starting them.

Self-care that can help to treat depression

Exercise: Sport and/or walks in the fresh air have a very positive effect on a person’s mood.
Nutrition: Eating a healthy, balanced diet is not only good for the body but can also have a positive effect on a person’s mental state.
Socialising: Making an effect to maintain an active social life and spend time with family and friends rather than secluding yourself is a positive move.
Try new things: There are plenty of ways to look after your mental health, such as yoga, saunas and other wellbeing programmes which promote relaxation and help to reduce stress.
Be consistent: It is important that a patient does not stop taking antidepressants as soon as their mood improves. Regular doctor’s appointments and therapy sessions are important in ensuring the therapy’s long-lasting success.

Sources
Dr Brigitte Schmid-Siegel, Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna; Die postpartale Depression, Spectrum Psychiatrie 03/2015, MedMedia Verlag und Mediaservice GmbH [in German]

Dr Hans-Peter Kapfhammer, Department of Psychiatry, Medical University of Graz; “Organische Depression” versus komorbide Depression bei somatischen Krankheiten, neuro Supplementum 03/2015, Austrian Neurology Society [in German]

Prof. Florian Holsboer, CEO of HMNC GmbH, Munich; Depression: personalisierte Therapie, Clinicum Neuropsy 06/2014, Medizin Medien Austria GmbH [in German]

Dr Gabriele Sachs, Department of Psychiatry and Psychotherapy, Medical University of Vienna; Kognition bei Depression, Clinicum Neuropsy 04/2014, Medizin Medien Austria GmbH [in German]

International Statistical Classification of Diseases and Related Health Problems (ICD), ICD-10, Version 2013, World Health Organization

Dr Siegfried Kasper, Department of Psychiatry and Psychotherapy, Medical University of Vienna; Unipolare Depression, Clinicum Neuropsy 05/2011, Medizin Medien Austria GmbH [in German]

Autor: Katharina Miedzinska, MSc