Clinical Depression

What does the term “clinical depression” mean?

Depression ranges in seriousness from mild, temporary episodes of sadness to severe, persistent depression. Clinical depression is the more severe form of depression, also known as major depression or major depressive disorder. It isn’t the same as depression caused by a loss, such as the death of a loved one, or a medical condition, such as a thyroid disorder.

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To be diagnosed with clinical depression, you must meet the symptom criteria for major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

For clinical depression, you must have five or more of the following symptoms over a two-week period, most of the day, nearly every day. At least one of the symptoms must be either a depressed mood or a loss of interest or pleasure. Signs and symptoms may include:

  • Depressed mood, such as feeling sad, empty or tearful (in children and teens, depressed mood can appear as constant irritability)
  • Significantly reduced interest or feeling no pleasure in all or most activities
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected)
  • Insomnia or increased desire to sleep
  • Either restlessness or slowed behavior that can be observed by others
  • Fatigue or loss of energy
  • Feelings of worthlessness, or excessive or inappropriate guilt
  • Trouble making decisions, or trouble thinking or concentrating
  • Recurrent thoughts of death or suicide, or a suicide attempt

Your symptoms must be severe enough to cause noticeable problems in relationships with others or in day-to-day activities, such as work, school or social activities. Symptoms may be based on your own feelings or on the observations of someone else.

Clinical depression can affect people of any age, including children. However, clinical depression symptoms, even if severe, usually improve with psychological counseling, antidepressant medications or a combination of the two.

Who Is at Risk for Major Depression?

Major depression affects about 6.7% of the U.S. population over age 18, according to the National Institute of Mental Health. Overall, between 20% and 25% of adults may suffer an episode of major depression at some point during their lifetime.

Major depression also affects older adults, teens, and children, but frequently goes undiagnosed and untreated in these populations.

clinical-depression-1Are Women at Higher Risk for Major Depression?

Almost twice as many women as men have major or clinical depression; hormonal changes during puberty, menstruation, pregnancy, miscarriage, and menopause, may increase the risk.

Other factors that boost the risk of clinical depression in women who are biologically vulnerable to it include increased stress at home or at work, balancing family life with career, and caring for an aging parent. Raising a child alone will also increase the risk.

clinical-depression-2Symptoms of Clinical Depression

The symptoms of depression can be complex and vary widely between people. But as a general rule, if you’re depressed, you feel sad, hopeless and lose interest in things you used to enjoy.

The symptoms persist for weeks or months and are bad enough to interfere with your work, social life and family life.

There are many other symptoms of depression and you’re unlikely to have all of those listed below.

Psychological symptoms

The psychological symptoms of depression include:

  • continuous low mood or sadness
  • feeling hopeless and helpless
  • having low self-esteem
  • feeling tearful
  • feeling guilt-ridden
  • feeling irritable and intolerant of others
  • having no motivation or interest in things
  • finding it difficult to make decisions
  • not getting any enjoyment out of life
  • feeling anxious or worried
  • having suicidal thoughts or thoughts of harming yourself

Physical symptoms

The physical symptoms of depression include:

  • moving or speaking more slowly than usual
  • changes in appetite or weight (usually decreased, but sometimes increased)
  • constipation
  • unexplained aches and pains
  • lack of energy
  • low sex drive (loss of libido)
  • changes to your menstrual cycle
  • disturbed sleep – for example, finding it difficult to fall asleep at night or waking up very early in the morning

Social symptoms

The social symptoms of depression include:

  • not doing well at work
  • avoiding contact with friends and taking part in fewer social activities
  • neglecting your hobbies and interests
  • having difficulties in your home and family life

Clinical Depression Treatment and Drugs

Medications and psychological counseling (psychotherapy) are very effective for most people with depression. Your primary care doctor or psychiatrist can prescribe medications to relieve symptoms. However, many people with depression also benefit from seeing a psychologist or other mental health professional.

If you have severe depression, you may need a hospital stay, or you may need to participate in an outpatient treatment program until your symptoms improve.

Here’s a closer look at depression treatment options.

Medications

Many types of antidepressant medications are available, including those below. Discuss possible major side effects with your doctor or pharmacist.

  • Selective serotonin reuptake inhibitors (SSRIs).Doctors often start by prescribing an SSRI. These medications are safer and generally cause fewer side effects than other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs).Examples of SNRIs include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla) and levomilnacipran (Fetzima).
  • Norepinephrine-dopamine reuptake inhibitors (NDRIs).Bupropion (Wellbutrin, Aplenzin, Forfivo XL) falls into this category. It’s one of the few antidepressants not frequently associated with sexual side effects.
  • Atypical antidepressants.These medications don’t fit into any other antidepressant categories. Trazodone and mirtazapine (Remeron) are sedating and usually taken in the evening. Newer medications include vortioxetine (Brintellix) and vilazodone (Viibryd). Vilazodone is thought to have a low risk of sexual side effects.
  • Tricyclic antidepressants.These antidepressants — such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin, trimipramine (Surmontil), desipramine (Norpramin) and protriptyline (Vivactil) — can be very effective, but tend to cause more-severe side effects than newer antidepressants. So tricyclics generally aren’t prescribed unless you’ve tried an SSRI first without improvement.
  • Monoamine oxidase inhibitors (MAOIs).MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan) — may be prescribed, typically when other medications haven’t worked, because they can have serious side effects. Using MAOIs requires a strict diet because of dangerous (or even deadly) interactions with foods ― such as certain cheeses, pickles and wines ― and some medications including birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), a newer MAOI that sticks on the skin as a patch, may cause fewer side effects than other MAOIs do. These medications can’t be combined with SSRIs.
  • Other medications.Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or adding medications such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications also may be added for short-term use.

Finding the right medication

If a family member has responded well to an antidepressant, it may be one that could help you. Or you may need to try several medications or a combination of medications before you find one that works. This requires patience, as some medications need several weeks or longer to take full effect and for side effects to ease as your body adjusts.

Inherited traits play a role in how antidepressants affect you. In some cases, where available, results of genetic tests (done by blood test or cheek swab) may offer clues about how your body may respond to a particular antidepressant. However, other variables besides genetics can affect your response to medication.

Risks of abruptly stopping medication

Don’t stop taking an antidepressant without talking to your doctor first. Antidepressants aren’t considered addictive, but sometimes physical dependence (which is different from addiction) can occur.

Stopping treatment abruptly or missing several doses can cause withdrawal-like symptoms, and quitting suddenly may cause a sudden worsening of depression. Work with your doctor to gradually and safely decrease your dose.

Antidepressants and pregnancy

If you’re pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn child or nursing child. Talk with your doctor if you become pregnant or you’re planning to become pregnant.

Antidepressants and increased suicide risk

Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires all antidepressants to carry a black box warning, the strictest warning for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior, especially when first beginning a new medication or with a change in dosage. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

Psychotherapy

Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as talk therapy or psychological therapy.

Different types of psychotherapy can be effective for depression, such as cognitive behavioral therapy or interpersonal therapy. Your mental health provider also may recommend other therapies. Psychotherapy can help you:

  • Adjust to a crisis or other current difficulty
  • Identify negative beliefs and behaviors and replace them with healthy, positive ones
  • Explore relationships and experiences, and develop positive interactions with others
  • Find better ways to cope and solve problems
  • Identify issues that contribute to your depression and change behaviors that make it worse
  • Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger
  • Learn to set realistic goals for your life
  • Develop the ability to tolerate and accept distress using healthier behaviors

Hospital and residential treatment

In some people, depression is so severe that a hospital stay is needed. This may be necessary if you can’t care for yourself properly or when you’re in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

Other treatment options

For some people, other procedures may be suggested:

  • Electroconvulsive therapy (ECT).In ECT, electrical currents are passed through the brain. Performed under anesthesia, this procedure is thought to impact the function and effect of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don’t work. Physical side effects, such as headache, are tolerable. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don’t get better with medications, can’t take antidepressants for health reasons or are at high risk of suicide.

Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven’t responded to antidepressants. During TMS, you sit in a reclining chair, awake, with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you’ll have five treatments each week for up to six weeks.