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Depression is one of the leading causes of disability worldwide. It is a disease that is both prevalent and potentially deadly: One in five Americans meets some of the criteria for Major Depressive Disorder at some point in their lives.

Yet the real rate of depression is likely much higher. An estimated two-thirds of depression cases go undiagnosed, in part because the disorder doesn’t always show up the way we imagine it should. Not every depressed person cries or stays in bed all day; in fact many appear fine to those around them. Some may conceal their internal struggle because of the lingering stigma that only “weak” people get depressed — another reason why rates of undiagnosed depression remain so high.

Sometimes, depression passes on its own. But prolonged, untreated depression can wreak havoc on careers and relationships, compound other mental and physical health issues, and lead to substance abuse or even suicide. That’s why it’s so important to know the warning signs and what to do about them. Read on for a review of the symptoms, risk factors, and treatment options for depression.

Explaining Depression

Some people experience chronic depression, with symptoms at varying degrees of severity for years or even for their entire lives. Others experience long stretches of a stable or even positive mood before falling into major depressive episodes. Still others have a low baseline mood marked by occasional severe episodes.

Whatever the pattern, depression consists of a range of symptoms, the most familiar of which involve mood and cognition. These include feelings of sadness and emptiness as well as self-defeating thoughts. Especially when it is persistent, depression can distort the way you see yourself, giving rise to beliefs that you are worthless and unlovable, or that things will never get better. This can contribute to irritability and anger — symptoms that don’t fit most people’s perception of depression.

Depressed individuals tend to feel physically and mentally lethargic even when they’ve slept a solid eight hours or more. In fact, hypersomnia, or excessive sleep, is a hallmark symptom — though some struggle to sleep at all. Accordingly, depression takes a toll on energy. Some depressed people actually move more slowly, as if they’re set at half speed, while others feel foggy and struggle with concentration and memory.

A change in appetite and weight swings are also common. But the two can go in either direction: While depression blunts appetite for some, others overeat. In either case, food rarely serves as a source of pleasure; one study found that food actually tastes different when we’re depressed.

The inability to experience pleasure, or anhedonia, is another common sign. This, coupled with low energy and mood, often leads depressed individuals to disengage from activities that would otherwise bring joy — a Catch-22 that can further exacerbate symptoms.

Finally, depressed individuals may experience thoughts of self-harm or even suicide. 

Causes of Depression

As with many mental illnesses, both nature and nurture contribute to depression.

The condition has a strong genetic component. Compared with those with no family history of depression, individuals who have an immediate family member with major depressive disorder are up to four times more likely to meet criteria for the disorder within their lifetime.

Yet our life experiences matter, too. Those who have experienced trauma are more likely to develop depression. This is particularly true for childhood trauma perpetrated by a caregiver, such as abuse or neglect. Major life changes, such as death, divorce, or job loss, can also trigger depression, though it’s normal to feel sad in these circumstances, and in many cases the symptoms fade naturally over time. (See below for more on distinguishing between depression and grief.)

Other risk factors include substance abuse, chronic illness, and lack of structure or supportive relationships. But it can be tough to discern whether these factors cause or are caused by depression. There tends to be a reciprocal relationship between mood and behavior, behavior and consequences, consequences and mood. For example, frequently turning to drugs or alcohol to cope with feelings of sadness may lead to poor job performance, relationship issues, and health complications (not to mention withdrawal, which can mimic symptoms of depression), all of which exacerbate the feelings of sadness.

When to Seek Help

Distinguishing between clinical depression and run-of-the-mill sadness boils down to a few key questions.

  • When did it start and why? Generally, symptoms lasting two weeks or more suggests you need help. If you’re feeling sad in response to a known stressor, such as divorce or job loss, it may be worth waiting to see if symptoms resolve on their own. Meanwhile, assess whether your feelings ebb and flow, which is typical of grief, or seem to hang around like a dark cloud. Also be on the lookout for feelings of hopelessness or anhedonia, both of which relate more closely to depression than grief.
  • How are symptoms interfering with your life? Consider whether you’re able to maintain your usual routines or if you’ve noticed things beginning to slide. Falling behind at work; bailing on social commitments; or struggling to sleep, eat, or maintain basic hygiene (in severe depressive episodes, even getting out of bed may seem inconceivable) should all be considered warning signs of depression.
  • Are you having thoughts of suicide or self-harm? You should take any thoughts of suicide seriously, but it’s important to distinguish between passive thoughts (Sometimes I wish I could go to sleep and never wake up) and active suicidal ideation. Actively planning or taking steps toward suicide, such as purchasing a gun, indicate that you need immediate help. The National Suicide Prevention Lifeline (800-273-8255) offers round-the-clock support, but if you aren’t sure that you can keep yourself physically safe, consider checking into a hospital.

Treating Depression

For mild or occasional depression, a few basic lifestyle changes can help. Commit to a regular sleep schedule. Exercise and spend time outside. Connect with loved ones. Engage in acts of service, which can include volunteering or simply checking in with a friend.

Persistent or debilitating depression requires a stronger arsenal. Studies show that a combination of therapy and medication tends to be most effective. Cognitive behavioral therapy (CBT), which involves learning to change self-defeating thoughts and behaviors, has long been a popular method for targeting depression.

Yet, some research suggests CBT — or any type of therapy — alone is not enough for more severe cases. Medication can be lifesaving, but it’s essential to follow your prescriber’s instructions and to remember that it takes time for any particular medication to work. Also, finding the right medication often involves some trial and error (though new forms of genetic testing are making it easier to identify the best fit).

The most severe forms of depression may be treated with Electroconvulsive Therapy (ECT) or Transcranial Magnetic Stimulation (TMS), both of which involve brain stimulation and should only be performed under the care of a medical professional. Promising research is also emerging around the effectiveness of ketamine. Initially used as an anesthesia, controlled infusions of ketamine have been shown to rapidly reduce symptoms.

No matter the course of treatment, it’s important to take depression seriously and talk about it honestly. Depression is real, common, and, most important, treatable — but only if you see the signs.

This article originally appeared as “Understanding Depression” in the March 2021 issue of Experience Life.

Alexandra Smith, MA, LPCC

Alexandra Smith, MA, LPCC, is a licensed professional clinical counselor in Minneapolis and an Experience Life contributing editor.

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