• Exhaustion on waking

• Disrupted sleep, sometimes through upsetting dreams

• Early morning waking and difficulty getting back to sleep

• Doing less of what they used to enjoy

• Difficulty concentrating during the day

• Improved energy as the day goes on

• Anxious worrying and intrusive upsetting thoughts

• Becoming emotional or upset for no particular reason

• Shortness of temper, or irritability

A person can be diagnosed as suffering from clinical depression if:

(A) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either

(1) depressed mood or
(2) loss of interest or pleasure.

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

(B) The symptoms do not meet criteria for a Mixed Episode.

(C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(D) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

(E) The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

The value of treatment

Depression interferes with the way people want to live their everyday lives. They may feel unable to go to work or do any of the things they used to enjoy. Despite this, many people do not seek help for their problems. This may be because they feel embarrassed about their feelings, considering them a sign of weakness, or because they blame themselves for their misfortune.

Fortunately, a number of treatments are available for depression and talking to a qualified professional about feelings is the first step.

Treatment options

The two main approaches to treating depression are psychological therapies, such as counselling, and medical treatment with antidepressants. These are described in greater detail in a separate BUPA factsheet called Depression treatments.

For mild forms of depression, psychological treatments are often sufficient. For more severe depression, a combination of psychological treatment and antidepressant drugs, or antidepressants alone, is usually recommended.

Regular physical exercise may also be helpful for mild to moderate depression.

Antidepressants

A wide range of antidepressant medication is now available. The two main types of antidepressants are known as SSRIs (which stands for selective selective serotonin re-uptake inhibitors) and tricyclics (the name refers to the molecular structure of the drug). They are both known to be effective in treating depression but SSRIs, a group of drugs which includes fluoxetine (Prozac), are now being more widely used because their side-effects tend to be slightly less troublesome.

Most antidepressants take at least two weeks to start working and their effects begin quite gradually. They are then usually required for around six months to treat a single episode of depression, even if the symptoms clear up sooner. This is because it’s been shown that a longer course makes a relapse of depression less likely.

Complementary therapy

St John’s wort (Hypericum perforatum) is now a popular complementary medicine for depression. It can be bought as tablets in health food stores and pharmacies. Some research studies have shown some promising results in treating mild to moderate depression. If you are taking prescription or over the counter medicines, ask for advice from your doctor or pharmacist before taking St John’s wort, as there can be harmful interactions.

Psychological treatment

GPs can often arrange for people with depression to have counselling as part of their treatment, and counsellors are sometimes based at the surgery. Counselling usually takes the form of a one-to-one session where you have an opportunity to express your feelings and problems, with the counsellor listening and asking questions. Generally in counselling, you won’t be told what to do about these feelings. A typical course of counselling is around six sessions.

More structured types of psychological treatment also exist. These include cognitive behavioural therapy and psychotherapy.

Further help

For the majority of people, depression responds to antidepressants and counselling. If depression is severe, or intense thoughts of suicide are experienced, GPs often refer sufferers to a psychiatrist. Psychiatrists are qualified doctors who have specialist training in treating mental health problems. A psychiatrist can suggest a wider range of therapy, both medical (medicines) and psychological.

Sometimes, people need to be admitted to hospital for severe depression. They (or their family) may feel they are unsafe to be looked after at home, due to suicidal thoughts. Depressed people are not typically a danger to others.

Prevention

Learning to manage stress is an important factor in the prevention of depression. Stress is a highly individual experience; we all have different things in our lives that cause frustration or unhappiness. We all need to be aware of how we are feeling and of how to develop positive ways of coping. This may simply mean making more time to relax, exercise, or learning to talk more openly with people you are close to.

ALTHOUGH it is often classed as 'mental illness', clinical depression often has as many physical symptoms as mental. The feelings or emotions that are depression symptoms actually begin to cause the physical effects. How this happens is a vital part of understanding depression and the symptoms that come with it.

If you are depressed at the moment some of the following symptoms may sound familiar:

• You feel miserable and sad.

• You feel exhausted a lot of the time with no energy .

• You feel as if even the smallest tasks are sometimes impossible.

• You seldom enjoy the things that you used to enjoy-you may be off sex or food or may 'comfort eat' to excess.

• You feel very anxious sometimes.
  

• You don't want to see people or are scared to be left alone. Social activity may feel hard or impossible.
  

• You find it difficult to think clearly.
  

• You feel like a failure and/or feel guilty a lot of the time.
  

• You feel a burden to others.
  

• You sometimes feel that life isn't worth living.
  

• You can see no future. There is a loss of hope. You feel all you've ever done is make mistakes and that's all that you ever will do.

• You feel irritable or angry more than usual.
  

• You feel you have no confidence.
  

• You spend a lot of time thinking about what has gone wrong, what will go wrong or what is wrong about yourself as a person. You may also feel guilty sometimes about being critical of others (or even thinking critically about them).

• You feel that life is unfair.
  

• You have difficulty sleeping or wake up very early in the morning and can't sleep again. You seem to dream all night long and sometimes have disturbing dreams.
  

• You feel that life has/is 'passing you by.'
  

• You may have physical aches and pains which appear to have no physical cause, such as back pain.
  

It's this wealth of depression symptoms, and the broad scope that confuses many people as to what depression actually is. Explanations rarely cover all the symptoms, and everybody's experience is different.

Who is affected

Depression affects up to 40% of people at some point in their lives. It often appears first during a persons teens or twenties. Some people then experience recurrent episodes – or bouts – throughout their lives. It is twice as common in women than men.

Symptoms

The most common symptom of depression is low mood. In addition to feeling sad, some people are irritable and tend to lose their temper more easily than usual. Often, people notice that they feel worse either first thing in the morning or last thing at night.

Depressed people find that they can’t get pleasure from events or activities that they normally would. They tend to feel different and separate from the rest of the world.

Lack of energy, tiredness and poor concentration are also common symptoms. Additionally, sufferers find they don’t sleep well, either waking up unrefreshed from a long sleep, or waking up very early in the morning. Loss of sex-drive (libido) and disturbed eating patterns – either loss of appetite or eating too much – are also common.

Symptoms of anxiety routinely occur with depression. People may experience fearfulness, palpitations and even panic attacks. Very often these feelings subside when the depression is treated.

One of the most serious aspects of depression is the thoughts people have about themselves and their lives. Sufferers start to judge themselves excessively harshly or critically. They may think of harming themselves or feel that life is not worth living. People who are depressed are more likely than others to attempt suicide.

Many people with depression turn to alcohol or illegal drugs to try and blot out their difficult feelings. Unfortunately, this tends to make things worse. Alcohol, for example, lowers the mood further and, in excess, is harmful to physical health.

What causes depression?

Usually a bout of depression is set off by a stressful event, often involving some form of loss. This may be when somebody dies, or when a relationship breaks down.

Financial worries, a stressful job, redundancy or fear of unemployment, even moving house, can trigger depression in vulnerable people. New mothers are susceptible to postnatal depression (please see the separate BUPA fact sheet on postnatal depression). And long-term or serious illnesses such as diabetes or cancer can also trigger depression.

Relationship problems are common in depressed people. These may be part of the cause of a person’s depression or a consequence.

Some forms of the illness seem to run in families, but researchers have yet to find a simple genetic explanation. Unhappy childhood experiences have been shown to be important in the development of depression in adult life. For example, a child who loses his or her mother before the age of 14 and lacks adequate care from another person is more likely to develop depression. Other difficult childhood events such as sexual abuse are linked to depression in adult life.

Lastly, some people tend to always look on the darker side of things – it’s part of their personality. These people are more likely to develop full-blown depression at some point in their lives.