Depression - Causes, Symptoms and Treatment

Depression, also called major depressive disorder or unipolar depression, is a psychiatric disorder capable of causing numerous psychological and physical symptoms. Its most well-known symptom is a deep and prolonged sadness, which does not mean that all sadness is necessarily related to a picture of depression.


Most adults with a depressive disorder are never evaluated by a psychiatrist, as their symptoms are often not properly recognized. This confusion occurs even among physicians not accustomed to dealing with problems related to mental health.

Studies show that more than half of the patients seen by general practitioners who present physical symptoms of depression, such as pain, insomnia or chronic fatigue, end up not being recognized as such. The correct diagnosis ends up appearing only after months or years of symptoms and several consultations with different physicians.

What is depression?

Major depressive disorder is a chronic, extremely common psychiatric disorder characterized by a change in the patient's mood that leaves him sad beyond normal, discouraged, lacking energy, low self-esteem, and having difficulty coping with his personal and professional life.

Depression was a poorly understood disease for decades, which led to misinterpretations about its causes and symptoms, causing stigmatization of its carriers. Until today it is common to find depressed people who do not accept their diagnosis or family / friends who treat the depressed patient as someone mentally weak, unable to overcome the difficulties of life. One should not treat the depressed patient as simply sad, unable to react.

More than just an attack of sadness, depression is not a weakness or lack of discipline, nor is it something that the patient can simply solve with his own will. For the depressed, to stop being sad is not that neither the smoker who wants to stop the cigarette; it is not a matter of making the decision and staying true to it. Depression is a chronic disease that usually requires long-term treatment, such as diabetes or hypertension. Just as no one stops being diabetic just with willpower and positive thinking, depression also needs medical help to be controlled.

Depressive disorder can arise at any stage of life, from infancy to old age. It is so common a disease that it is estimated that 12% of men and up to 25% of women will experience some degree of depression throughout their lives. This disorder is twice as common in women as men and is more common in young adults than in the elderly.

Also read article "What is depression?".

Differences between sadness and depression

The term depressed is often used as a synonym for sad. Sadness and depression are different things. In fact, sadness is usually one of the symptoms of depression, but it alone is not enough for its diagnosis.

Sadness is a normal and expected reaction to many situations, such as the death of a loved one, the end of a loving relationship, loss of employment, etc. It is quite normal for the individual to spend a few sad days or weeks after loss situations. This is not considered a major depressive disorder.

To be depressed, the picture of sadness has to be prolonged and above normal, enough to interfere with a person's daily activities, reducing the capacity to take care of oneself, disrupting relationships, harming their professional assignments, etc. If you lose a relative and feel sad for weeks, this is normal. But if this sadness is so intense that weeks after the loss you still can not resume your life on basic issues like working, maintaining personal hygiene, taking care of the home, this can be depression.

In sadness, the individual usually presents improvement periods throughout the day, managing to forget at times the cause of his sadness, such as during a visit of a loved one. In depression, the feeling is continuous and does not relieve with the help of others. Depression usually also causes a sense of guilt, but for no apparent reason. The depressed feels a heavy guilt, but can not explain why.

It is good to point out that the depressed patient does not always present to friends and family that classic behavior of excessive sadness. Depressive disorder may be more subtle, manifesting as a loss of interest in previously enjoyable activities, lack of plans for the future, changes in sleep patterns, social isolation or low self-esteem. To be depressed you do not have to spend all day in bed crying.

Sadness always has a cause, depression does not. Obviously, the death of a close person can trigger a depressive disorder, but not always sad situations need to occur for the individual to start a picture of depression.

Causes of depression

As with many psychiatric illnesses, there is no single cause for depression. The disease seems to be triggered by the interaction of several factors, be they physical or psychological.

1. Organic factors responsible for depression

Depression does not just come from emotional or psychological problems. Several risk factors and organic causes have been recognized for major depressive disorder.

1.1. Genetics
People who have family members with depression are at increased risk of developing the disease, indicating that there is a vulnerability to depression that can be genetically inherited. In fact, having close relatives with other psychiatric illnesses, such as panic syndrome, affective disorders or even alcoholism, are also risk factors for depression.

Despite intense studies in the area, the genes responsible for vulnerability to depression have not yet been identified.

Although genetic inheritance is apparently an important factor, it alone is not enough to trigger the disease. This is easily proven through studies of identical twin siblings, where it was found that there is agreement in only 40% of cases. Therefore, factors other than genetics are necessary for the depressive disorder to arise.

1.2. Neurotransmitters
The human brain is a highly complex structure whose functioning depends on hundreds of chemical mediators. We now know that most psychiatric illnesses are related to at least 5 of these neurotransmitters: noradrenaline, serotonin, dopamine, gamma aminobutyric acid (GABA), and acetylcholine.

The abundance or lack of some of these neurotransmitters in certain parts of the brain can trigger serious psychiatric and neurological disorders. Examples: a lack of dopamine in certain areas of the brain base causes Parkinson's disease. Alzheimer's disease appears to be related to low levels of acetylcholine in the brain.

Depression results from the abnormal functioning of some of these neurotransmitters, such as dopamine, serotonin, noradrenaline, and GABA. Among these, serotonin seems to play the most relevant role, being usually at reduced levels in patients with depression.

1.3. Use of drugs or alcohol
Dependent diseases are also under the influence of these neurotransmitters cited above. Drugs and alcohol exert their effects by increasing the release of dopamine in the brain, which causes euphoria and a pleasant sensation. The problem is that repeated use of drugs or alcohol desensitizes the dopamine system, causing it to become accustomed to the presence of these substances. Therefore, addicted people need more and more drugs or alcohol to reach the same degree of satisfaction, and may leave them depressed when they are out of the effect of these substances. The brain is accustomed to living with increasingly high levels of stimulating neurotransmitters, causing normal levels to become insufficient to control the mood of the individual.

1.4. Brain changes
In addition to reducing the concentration of neurotransmitters, patients with chronic depressive disorder also have changes in the anatomy of the brain, such as volume reductions of the frontal lobe and hippocampus.

Neuroimaging studies also show changes in the functioning of various brain areas in people with depression. Researchers have discovered an area of the prefrontal cortex with abnormally decreased activity in patients with this disorder. This region is related to the emotional response and has generalized connections with other areas of the brain responsible for the regulation of humoral neurotransmitters such as noradrenaline, dopamine and serotonin.

1.5. Brain diseases
The relationship between stroke and the onset of depression is increasingly accepted. We know today that the depression that arises after a stroke is not only caused by psychological shocks because of the perceived consequences of stroke, such as motor or speech sequelae. Direct brain injury from stroke increases the risk of onset of depression, even if the consequences of stroke do not have a major psychological effect on the patient.

In addition to stroke, several other neurological diseases increase the risk of depression, including Parkinson's, Alzheimer's, multiple sclerosis, epilepsy, tumors and cranial trauma.

1.6. Chronic diseases
Patients with chronic diseases are also more vulnerable to the onset of depressive disorder. The most common are: diabetes, heart disease, hypothyroidism, AIDS, cirrhosis, inflammatory bowel disease, lupus, rheumatoid arthritis, fibromyalgia, among others.

2. Psychological factors associated with depression

Emotional stresses are an important trigger for the onset of depression. Often, a traumatic event is a missing factor for an individual likely to develop a depressive process.

2.1. Trauma in childhood
Trauma acquired in childhood is an important risk factor for the development of depression. Among the traumas are abuses, absence of the father, death of a near entity, aggressions or lack of affectivity on the part of the parents.

Problematic relationships with parents, siblings and colleagues are common in children and adolescents with depression. Depressive adults also often report poor paternal involvement and maternal overprotection during early childhood.

Children who have been bullied are also at greater risk of becoming depressed.

2.2. Emotional stresses
Although depressive disorder may arise without any precipitating emotional factor, personal stresses and losses certainly increase the risk. Losses of loved ones are important risk factors in younger individuals. In the elderly with long marriages, the loss of the spouse or wife is also often a triggering event of depression.

Chronic pain, chronic illness, disability and diseases that leave sequelae can also lead to depression.

Social isolation, excessive criticism and collections on the part of the family, persistent economic difficulty, separation of marriage or low self-esteem are also common factors.

Having close and frequent contact with someone who is depressed also increases the risk of depression.

2.3. Postpartum depression
Postpartum depression is a kind of depressive disorder that some women develop after giving birth. Most women with postpartum depression begin to experience symptoms in the first month of their baby's life, but some take up to 12 months to develop depressive symptoms. About 10% of mothers suffer from postpartum depression.

In the first 2 or 3 days after having a baby, many women often have a mild type of postpartum depression, called postpartum sadness or postpartum melancholia. This condition affects up to 80% of mothers and is characterized by moodiness, irritation, difficulty concentrating, insomnia and crying crises.

Postpartum melancholy occurs due to hormonal changes that occur with the termination of pregnancy and psychological stresses caused by the responsibility of caring for a newborn, associated with the physical fatigue that the task causes. In most cases, postpartum sadness disappears in 2 to 3 weeks.

Postpartum depression is a more important picture than postpartum melancholia, lasting longer and presenting more severe symptoms. Women with a history of depression are more likely to have postpartum depression than women who have never been depressed.

Women with postpartum depression often can not sleep, even when their babies sleep. In addition they are very irritated, unable to take care of the baby, with a serious feeling of guilt and with feeling of having no affective ties with the new child.

Postpartum depression may lead the mother to have thoughts of hurting herself and the baby, in most cases, however, the mother can recognize the absurdity of the idea, having the ability to control this strange thought.

Postpartum depression may disappear spontaneously, but medical help is important because in some cases the depressive disorder does not improve over time and there are risks for the mother to inflict harm on the child.

Symptoms of depression

Depressive disorder is a disease that can manifest itself in a variety of ways. The most common form is the so-called major depressive disorder, also known as major depression. Another very common form is chronic depression, which is called dysthymia. Other types of depression that may occur are bipolar disorder, seasonal depression, reactive depression, atypical depression, postpartum depression, and minor depression.

Major depression usually presents at least five of the nine symptoms listed below, one of which is necessarily sadness or loss of interest in daily activities.
  • 1. Sadness for most of the day, particularly in the morning
  • 2. Loss of interest in day-to-day activities
  • 3. Significant changes in appetite or weight (may be increase or decrease)
  • 4. Insomnia or excessive sleep
  • 5. Agitation or lethargy
  • 6. Fatigue or persistent lack of energy
  • 7. Feelings of worthlessness or guilt
  • 8. Inability to concentrate and indecision
  • 9. Recurring thoughts about death or suicide

To be considered major depressive disorder criteria, the symptoms listed above should be daily and should be present for more than 2 consecutive weeks.

Diagnosis of depressive disorder

The diagnosis of depression is preferably made by the psychiatrist and is based on the symptoms, duration and overall effects they cause in the patient's life. There is currently no laboratory or imaging test that identifies depression, although some blood tests may be done to rule out other diseases with similar symptoms, such as hypothyroidism, for example.

The diagnosis of major depression requires that the symptoms be severe enough to interfere with the patient's daily activities and the ability to take care of oneself, maintain relationships, participate in work activities, etc. The diagnosis also requires that the symptoms are occurring daily for at least two weeks.

After the diagnosis it is important to try to identify suicidal thoughts, so that the appropriate treatment is instituted as soon as possible.

Treatment of depression

Initial treatment of major depression should include antidepressant medications and psychotherapy, which can be done with a psychiatrist or psychologist.

Studies show that combined treatment (drugs + psychotherapy) is more effective than single treatment with only one of two options. Psychotherapy and antidepressant medications are equally effective, but psychotherapy has a more relevant long-term effect as it helps the patient to develop new coping ways of symptoms as well as a greater ability to rationalize and adapt to life's problems.

Antidepressant medications

There are dozens of drugs with antidepressant action in the market. Currently, the most used classes are:
  • Selective serotonin reuptake inhibitors (SSRIs or SSRIs) - Ex: Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline.
  • Selective serotonin and noradrenaline reuptake inhibitors (ISRSN or SNRI) - Ex: Venlafaxine, Duloxetine, Milnacipran and Desvenlafaxine.
  • Atypical antidepressants - Ex: Mirtazapine, Bupropion, Trazodone and Nefazodone.

Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (eg seleginine, amitriptyline, nortriptyline and imipramine) are older drugs that are currently poorly used in the treatment of depression because they have many side effects.

Doctors usually begin treatment for depression with a selective serotonin reuptake inhibitor (SSRI or SSRI) because it is a safe class of antidepressants with a low rate of side effects. Selective serotonin and noradrenaline reuptake inhibitors (SSRIs or SNRIs) are also a good alternative for initiating treatment.

There is no ready-made prescription that can be applied to all patients with depression. The medicine to be chosen depends on the clinical characteristics and the financial conditions of the individual. For example, if the patient has difficulty sleeping in addition to depression, drowsiness drugs such as mirtazapine may be the best choice.

Antidepressants may take time to achieve their full effect, many people only start to feel better after two weeks. However, to feel the full effect of the drug, the patient may take up to 6 to 12 weeks. Still, if the patient does not report relief of their symptoms after four weeks of treatment, the psychiatrist may increase the dose, add a new medication or simply replace the previous one. It is important to keep in mind that the response to antidepressants is individual and that the treatment may take weeks to adjust.

The occurrence of side effects may be a reason for drug substitution. Some side effects disappear over time, but others do not. Finding the right medication or combination of medications in the right doses sometimes takes time and requires a bit of trial and error. The important thing is not to be discouraged.

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