We all feel sad or lethargic every now and then. And we have all felt down or even desperate at some point in our lives. These phases are a normal part of life, and people usually feel better again after a while. Things are different for people who have depression. Their sadness and negative thoughts last longer and overshadow all of their thoughts and actions. Depression can arise without any triggering events or for no apparent reasons. People often feel like they are stuck in a black hole. They feel cheerless, lack motivation and self-confidence, and think of themselves as worthless. This can make it difficult to do everyday things like going to work or studying. Friends, family and hobbies are often neglected. They don't sleep well.
Depression can also make family and friends feel worried, anxious and helpless. Often they want to help but don't know how. It's not always easy for them to tell whether it's a passing phase or a serious illness.
People who have depression fall into an emotional black hole for weeks or months, and often can't see any way out. Different people experience depression differently: Some mainly feel sad and down. Everything seems pointless. Nothing and nobody can lift their spirits. Others aren't sad, but instead feel empty inside, exhausted and emotionally numb. And others may suffer from agonizing worries, fears and anxiety. Typical signs of depression include:
- Feeling down all the time
- Loss of energy and motivation, exhaustion
- Lack of joy and interest, even in things and hobbies that used to be enjoyable
- Low self-esteem and low self-confidence
- Feeling guilty and constantly brooding over things
- Difficulties concentrating and making decisions
- Apathy and emotional numbness
- Withdrawing from friends and family
- Hopelessness and worrying about the future
- Not wanting to live anymore, or suicidal thoughts
Physical symptoms that are sometimes associated with depression include:
- Sleep problems
- Loss of appetite
- Weight loss or gain
- Loss of sexual desire
- Digestion problems, such as constipation
- Increased sensitivity to pain
Physical symptoms like these are particularly common in older people.
Depression can arise at any age, in various phases of life and under various circumstances. These things influence the symptoms of depression and – sometimes – the way people and those around them experience depression too. For example, in older people, depression is often wrongly interpreted as a sign of old age or dementia.
Causes and risk factors
The cause of depression is not exactly clear. It is thought that various things play a role. These include biological factors, psychological factors, a person’s individual circumstances and particular events in their lives. Here are some examples of things that can make depression more likely and influence the course of the disease:
- Genes: People have an increased risk of depression if other people in their family have had depression
- Traumatic childhood experiences, such as abuse and neglect
- Chronic anxiety disorders in childhood and puberty, combined with low self-esteem and insecurity
- Biochemical changes: The metabolism in the brain has been found to be different in people with depression, and nerve impulses travel more slowly Certain chemical messengers and hormonal changes can also play a role
- Personality traits such as a lack of self-confidence
- Dependence on alcohol, tablets or drugs: This is sometimes a consequence of depression, but it might also be one thing that leads to depression or could make it worse
- Physical medical problems such as strokes, heart attacks, cancer or an underactive thyroid
- Taking particular medications
- Distressing events such as the death of a loved one or the end of a relationship
- Long-term stress and feeling like you can't cope, or feeling under-challenged
- Lack of light: The dark fall and winter months can lead to depression in some people
The course of depression can vary greatly. In many people things get better after a few weeks or months – even without treatment – and the depression doesn't come back. Others have regular phases of depression followed by depression-free phases. Some people have depression over a long period of time, with severe phases and less severe phases, while others develop chronic depression.
The typical symptoms of depression last at least two weeks, but may continue for up to several months. If they go away again after a certain amount of time, that period is considered a "depressive episode." Research shows that about half of all people who are treated for depression feel a noticeable improvement in symptoms after about three to six months.
If depression comes back within six months after the last depressive episode, it is called a relapse. If depression comes back more than six months after the last episode, or even years later, it is called recurrent depression. If depression returns several times, then the depression-free phases might get shorter and the depressive episodes might get longer over the years. A depressive episode that lasts longer than two years is considered to be chronic depression.
Depression makes people feel and behave differently than they used to. They often feel like it's their own fault, and are plagued by self-doubt. Many say they have feelings that they can no longer control or cope with. They may also have suicidal thoughts. People often become withdrawn, avoid social contact and hardly leave the house any more. They might start abusing alcohol, medicine or other drugs. These things can make the depression carry on longer, and could make it worse. It is often only possible to stop this vicious circle with the help of other people.
Some people have such severe depression that they can't summon the energy to get help and see a doctor. Other people don't see their own suffering as part of a treatable illness, but instead believe that they feel that way because they are a failure or weak-willed, or due to stress at work or in their private lives. Then it's important for their family and friends to offer support and go to the doctor with them.
To find out whether someone has depression, psychotherapists do two things: They ask about symptoms that could be signs of depression. They also try to rule out other illnesses or health problems that can cause similar symptoms. To do so, the doctor might need to perform physical examinations or tests too.
The typical symptoms of depression can be divided up into “core symptoms” and “secondary symptoms.”
The core symptoms include:
- Low mood, sadness, feeling down
- Lack of interest and joy
- Lack of motivation and feeling very tired, even after minor activities
The secondary symptoms help to determine how severe the depression is:
- Loss of appetite
- Sleep disorders
- Difficulty concentrating and making decisions
- Low self-esteem
- Feelings of guilt
- Negative and pessimistic thoughts about the future
- Suicidal thoughts or suicide attempts
If someone has several core and secondary symptoms over a period of two weeks or longer, they are diagnosed with depression. Special questionnaires about the symptoms are often used to help with the diagnosis. Depending on the number, type and severity of symptoms, the depression is considered to be mild, moderate or severe. The treatment options will depend on how severe the depression is.
Distressful experiences like a major loss or chronic stress are likely to contribute to the development of depression. Avoiding negative influences or learning to deal with them can help lower the risk. The people in your life also play a role. Having stable relationships lowers the risk of depression. And getting psychological help or counseling early on can also help to prevent depression. For people at a high risk of recurring depression, long-term treatment with medication might be considered in order to prevent a relapse. Some people have regular psychological treatment sessions over a long time period instead.
Many people who have depression find it hard to accept that fact. One possible reason for this is that they are ashamed about having a mental health problem and don't want their friends, family and colleagues to find out. Some people don't want to have treatment as a result. But treatment can often shorten depressive episodes and relieve people's symptoms.
There are various treatment options for depression. The main treatments are psychological treatment, such as cognitive behavioral therapy, and/or medication. Which type of treatment is the most appropriate, where it should take place and how long it lasts will depend on several factors, including how severe the person’s depression is, their personal circumstances, and how their symptoms develop over time. People can talk to a therapist about the advantages and disadvantages of the possible treatments, as well as what they expect from treatment and any fears they might have.
Depression makes it difficult to cope in everyday life. The demands of work, private commitments and even small household chores can become a major effort. Relationships with partners, friends and family often change. Those close to someone with depression usually find it very distressing too. Emotional withdrawal and apathy can lead to arguments and people might become even more withdrawn.
Still: many who have mental health problems or illnesses do turn to their partner, family or friends first. It is also often those people who first notice the symptoms of depression and the changes. Their comfort and support is particularly important to those who have depression.
But partners, family and friends often find it hard to cope if the depression is severe. Some people who have depression prefer to seek professional help because they don't want to be a burden, or because they are ashamed and would rather not talk about their illness with those close to them. Self-help groups might be helpful here too.
Active help and support are especially important if there is reason to believe that someone is thinking of taking their life. Many depressed people have suicidal thoughts. Although they don't usually act on them, it is extremely important that these thoughts are taken seriously and that they talk to other people about how they are feeling. If that isn't possible in an acute situation, there are various places you can turn to for help. In Germany, these include social-psychiatric services (in German: Sozialpsychiatrische Dienste), crisis support centers and a special crisis helpline (Telefonseelsorge) which is anonymous and available 24 hours a day.
In Germany, most people with mental health problems or illnesses turn to their family doctor first when looking for professional help and advice. But you can also contact psychological support services, or the private practices of psychiatrists or psychotherapists. In urgent cases such as an acute risk of suicide, you can contact a practice that offers out-of-hours services, or the emergency outpatient services of a psychiatric hospital.
Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN) u.a. Unipolare Depression. S3-Leitlinie/Nationale Versorgungsleitlinie. Version October 4, 2016.
National Institute for Health and Care Excellence (NICE). Depression: recognition and management. Clinical Guideline. October 2009.
Patientenleitlinie zur Nationalen Versorgungsleitlinie. Unipolare Depression. Version 1.0. August 2011.
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