Depression is a very common and disabling illness, both in the U.S. and worldwide.  At any one point in time, 5% of the U.S. population suffers from moderate to severe depression.  In its most serious forms, it is diagnosed as either Major Depressive Disorder or Bipolar Disorder. An episode of severe depression, called Major Depressive Disorder, is suffered by 17% of Americans at some point in their lives.  A chronic state of depression lasting two or more years, psychiatrically called a Dysthymic Disorder, affects 2% of the American public.  Another 1% suffer from chronic Bipolar Disorder or manic-depression.  Depression can also accompany other psychiatric disorders.

While depression is a normal reaction to disappointing and painful events, this normal type of depression, which can qualify as a Major Depressive Disorder if it lasts at least two weeks, usually lifts within several days.  Even individuals suffering major permanent injury, such as becoming crippled for life, usually recover their emotional well-being in a matter of weeks.  However, in others, depression will develop for no clear reason, or will linger on much longer than normal after a traumatic effect, or will snowball into severe and disabling depression. The causes of depression include genetics, brain injury, toxins, tobacco, alcohol, marijuana and other drugs, personal loss, repeated hardships, physical illness, abuse, and inappropriate ways of dealing with life stresses.  A bad diet and lack of exercise might also be factors.

There have now been thousands of carefully controlled studies done on the treatment of depression. The large majority of these are medication studies, although there are also many studies using counseling, fish oil, exercise, light therapy, vitamins and minerals, cranial electrotherapy stimulation, magnetic stimulation, herbal treatments, and electroshock therapy. Sadly, most therapists use only a limited range of these treatments.

Psychologists and other non-medical therapists rely heavily on counseling, often excessively. Cognitive-behavioral counseling has most often been found to be of definite value, although what the success rate of the average counselor is when administering this or other talk therapies is unknown. The high success rates of medical center counseling studies are difficult to replicate out in the community.

Psychiatrists and other medical doctors may rely excessively on medications and often use a very restricted range of medications, primarily those still covered by patents and heavily promoted by pharmaceutical companies.  Medications will be covered in depth, but I will also cover non-medication treatments for depression.

Many good non-medical treatments for depression are also important for the general health of your entire body.  Anti-depressant medications themselves have been found to be associated with lower the rate of heart disease in depressed individuals and decrease mortality.  However, because anti-depressant medications can sometimes have serious side-effects, it may be best to try effective non-medication remedies first, when possible, or to use these in addition to medication in hopes that the amount of medication needed will be reduced or the effectiveness increased.  There is also an exciting new treatment with magnetic stimulation (rTMS) that has very few side-effects and may be worth considering before medication or in medication resistant cases.  An older cranial electrotherapy stimulation (CES) also looks worth trying.  Unfortunately, the $35,000 cost of the rTMS equipment means it is generally unavailable.  The CES equipment at $500 is more doable.

On this website, I have included notes from scientific studies. Many of these notes are technical and are meant for physicians, mental health therapists, or fellow psychiatrists who are not familiar with the research.  Brief summaries ("abstracts") are available on these issues on PubMed (Grateful Med) on the internet for free.  PubMed is the medical literature search engine of the National Library of Medicine.  I highly recommend it anyone interested in finding out the truth about medical issues.  Unfortunately, since much of the information is complex, I will do my best to summarize the findings here for you.  The web address is for PubMed is (http://www.ncbi.nlm.nih.gov./entrez/query.fcgi) or just type PubMed into your standard search engine and it will find the website for you.

Please read the nutrition section, since good nutrition and taking reasonable vitamin and mineral supplements is vitally important to treating psychiatric difficulties besides being important for healthy living in general.

Combination Treatment of Depression

I sometimes recommend counseling along with folate, fish oil, vitamin D, and exercise as an initial form of treatment. Giving these a try for several weeks before going on to medication or magnetic stimulation treatment could avoid considerable expense and the side-effects of medication treatments which trouble some patients.  Probably the mildest anti-depressant treatment in my experience has been 5-HTP.  While I have only treated 20 or so patients with it and only very recently, it has been very received by my patients.  In fact, some of the patients had not done well on other medications.  I have also started using acetyl-L-carnitine with positive feedback.  The research on both, while quite limited, is very encouraging.

In cases of severe depression, starting the above regimen along with the medication might be the best idea.  Hopefully, less medicine will be necessary and the medicine has a good chance of being more effective with the above supplements.  In any case, the large majority of patients with chronic conditions will need long-term maintenance of some anti-depressant medication.

Cut down on TV viewing, eliminate violent entertainment, spend more time with friends, and do activities that used to be enjoyable. The elimination of tobacco, marijuana and alcohol is also very important although also very difficult, especially tobacco and marijuana. All three of these forms of drug abuse have been repeatedly shown to be major causes of depression.  While all three are addictive and difficult to quit, the damage they do to the nervous system and body is very difficult to undo except by stopping their usage.

Counseling can often help deal with loss or with anger and abuse situations. Of course, no treatment program is going to eliminate all of the emotional trauma of living in an on-going abuse situation. Cognitive-behavioral counseling has helped in a large number of studies.  I strongly recommend reading my book on anger, found elsewhere on this website, for anyone struggling with angry feelings after having lived through or living in an abuse situation. Of course, I also recommend it to anyone who has a problem with verbally or physically attacking others.

People Not Good at Recognizing Depression: A Swiss study of 844 average adults gave them short stories of individuals experiencing severe depression or schizophrenia.  Only 40% of people recognized the depressed person as suffering from a mental illness while 60% said that they were in a crisis.  With the schizophrenia story, 74% did recognize that there was a problem with mental illness. Do people recognise mental illness? Factors influencing mental health literacy. Lauber C, Nordt C, Falcato L, Rossler W. Eur Arch Psychiatry Clin Neurosci. 2003 Oct;253(5):248-51. Ed: This may be one reason so many severely depressed and suicidal people don't seek help.

Two-Third Still Depressed Two Years Later: In a study of adults in a general population survey who were found to be depressed, 65% were still depressed after two years of follow-up. Negative life events had occurred more often in those who had remained depressed than in the others. High initial depression scores and a worsening of a subject's economic situation during the follow-up period were associated with failure to recover. Lack of use of health services was associated with non-recovery. Recovery from depression: a two-year follow-up study of general population subjects. Vlinamaki H, et al. University of Kuopio, Finland. . Int J Soc Psychiatry 2006 Jan;52(1):19-28. 

Bodily Symptoms May be Signs of Depression: Primary care physicians are more likely to hear the somatic complaints, the most common of which relate to fatigue, sleep problems, headaches, backaches, gastrointestinal difficulties. In a study of patients in a non-psychiatric practice who complained of a wide range of somatic symptoms, researchers were only able to find an actual cause for the symptoms 16% of the time. No organic cause was identified for the other 84%. If the patient had just 1 of the 10 somatic symptoms listed, the odds of a mood disorder were more than 40%. With 3 symptoms from that list, the odds jumped up to more than 60%. With 5 or more symptoms, odds were 90%. The more somatic symptoms the patient has, the higher the risk for depression as well as for a worsening depression.

     The presence of physical symptoms generally predict greater severity of depression. There is a direct correlation between the degree of physical symptom improvement and the ability to achieve remission. Continuation of physical symptomatology in a patient can lead to lack of remission. Depression is a recurrent illness. One study by Solomon and colleagues showed that 92% of depressed patients remain ill 1 month after treatment begins. Although the numbers decrease (63% at 3 months, 42% after 6 months, and 30% after a year), 18% are still ill after 2 years, and 12% remain ill after 5 years. Patients with residual symptoms more than 3 times as likely to relapse (Paykel).

National Survey Finds 16% Have Major Depression at Least Once in Lifetime, 6% in Past Year: The National Comorbidity Survey Replication (NCS-R) with 9090 adults responding nationwide in 2001-2 found that 6% of adults had a Major Depressive episode during the past year, and that 90% of the depressions were moderate to very severe. Of the depressions, 75% had comorbid axis 1 diagnosis which were usually primary. 51% got treatment but only 21% got adequate treatment. Average duration of episodes was 16 weeks. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS; National Comorbidity Survey Replication. JAMA. 2003 Jun 18;289(23):3095-105

Depression Hasn't Increased Since 1952: Arch Gen Psychiatry 2000;57;209. MGH study.

6% Swedish High School Students Suffering From Major Depressive Disorder, Especially Females: Ups J Med Sci 1998;103(2):77-145. Females 4:1, tobacco use twice as high in depressed. 6% prevalence, 12% life-time.

U.S. High School Females Much Higher Depression; Sexual Activity Linked to Higher Rates: 2224 Massachusetts high school students found that depressed students were much more likely to be female with an risk ratio (OR) for depression 3.28 times that for males, by far the strongest factor. Being sexually active without birth control had a risk factor of 1.81, with birth control 1.53 vs. not active 1.00. Tobacco use only slight effect for either sex 1.09. Healthy diet helped females with a risk ratio of 0.89. Physical fights were associated with more depression 1.20 for both sexes. Harvard. J Adolesc Health 2002 Sep;31(3):240-6

4.4% Major Depression in Past Month: 30 day U.S. prevalence of depression was 4.4% (6.1% for ages 15-24 and 3.9% for ages 45-54). Lifetime 17%. Am J Psychiatry 151:979-86

Assisted Living Current Major Depression 13%; Four out of Five No Treatment: 2,078 residents over age 64 in 193 assisted-living facilities were tested with the Cornell Scale for Depression in Dementia (CSDD). 13% were currently depressed, and only 18% of those were on antidepressants. Over one-third of residents had symptoms of depression, such as anxious expression, rumination, or worrying, and 25% displayed sad voice, sad expression, or tearfulness. Depression was significantly associated with medical comorbidity, social withdrawal, psychosis, agitation, and length of residence in the facility. Depressed residents were discharged to nursing homes at 1.5 times the rate of non-depressed residents. Rates of mortality were significantly higher only for those with severe depression. Depression in assisted living: results from a four-state study. Watson LC, Garrett JM, Sloane PD, Gruber-Baldini AL, Zimmerman S. Am J Geriatr Psychiatry. 2003 Sep-Oct;11(5):534-42

No Decrease in Current Major Depression (26%) in Neurology Group: At baseline, 40% of 300 new neurology clinic patients were currently depressed with 26% Major Depressive Disorder. At 8 months, 20 previously not depressed were depressed. Of the depressed, 78% still depressed including 85% of those with MDD. The outcome of depressive disorders in neurology patients: a prospective cohort study. Carson AJ, Postma K, Stone J, Warlow C, Sharpe M. J Neurol Neurosurg Psychiatry. 2003 Jul;74(7):893-6

Headaches Common in Depression: In a study of 34 men and 117 women suffering from a Major Depressive Disorder, 48% reported a history of migraine and  21% reported chronic daily headaches (CHD) during this episode. Higher HAMD depression scores, female gender, and chronic depression were independently associated with migraine or CDH. Risk factors associated with migraine or chronic daily headache in out-patients with major depressive disorder. Hung CI, Wang SJ, et al. Chang Gung University, Taiwan. Acta Psychiatr Scand. 2005 Apr;111(4):310-5.