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	Depression and Mood Disorders
	See also: 'Stress and the Workplace'
	Definition
	Depression affects millions of people each year in our society and is a major cause of work-related disability, utilization of medical services, and drug use. In the public mind, depression is often confused with unhappiness or a reaction stemming from a death of a loved one. These are natural emotions but do not represent a psychiatric illness. Depression, on the other hand, is a disorder that affects both the mind and the body in profound ways. A person with depression experiences great distress and is often inconsolable. He or she may suffer from sadness and guilt leading to outbursts of crying or lack of pleasure in all activities. In some cases there are tragic consequences, such as inability to eat or drink and suicide. The two basic categories of mood disorders are: major depressive disorder and bipolar, or manic-depressive, disorder. Major depression is marked by persistent, extreme, and inappropriate low mood, while bipolar depression is much less common and is marked by periods of excited states as well as periods of depression. Mood disorder is one of the most common and currently most treatable forms of mental illness. It is estimated that 23 percent of people will have two or more symptoms of depression, and 6 percent will have major depression or dysthymia (a mild form of depression) at some point in their lifetime. About 1 percent of the population has had bipolar disorder. At all ages it is important to seek help for symptoms of depression because of the risk of suicide.
	Cause
	In many cases there is no identifiable cause; in others a distressing event such as the death of a loved one or a life stress such as the loss of a job may trigger depression. Biological and psychosocial factors may interact and produce a mood disorder in a vulnerable person. There is evidence that a biochemical imbalance of the chemical messengers (neurotransmitters) that transmit signals between brain cells is associated with depression (chemical imbalance may also play a role in other mental disorders, such as schizophrenia). Specifically, a deficiency of the neurotransmitters norepinephrine and serotonin may be present. Antidepressants mitigate depression because they increase the supply of these neurotransmitters, thereby correcting the imbalance. Hormonal imbalance is also related to some forms of depression. For example, changes in cortisol seem to be related to sleep disturbance, which is present in most types of depression. A genetic link to depression is supported by adoption and twin studies, which indicate that vulnerability to mood disorders is inherited in certain people. Major depression is 1.5 to 3 times more common in close relatives of people with this disorder than in the general population. Bipolar disorder shows a higher rate of genetic transmission than unipolar illness. Personality traits such as passivity and dependency may increase some people's risk of developing depression. Other risks for depression may be borderline personality disorder and alcohol or drug abuse. See also: 'Effects of Alcohol Abuse'
	Diagnosis
	Criteria used by the American Psychiatric Association to diagnose a major depressive episode include: 1./ At least five of the following symptoms have been present during a 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure. Depressed mood most of every day Diminished interest or pleasure in almost all activities most of every day Significant weight loss or weight gain when not dieting Insomnia or hypersomnia nearly every day Restlessness or slowing down nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive guilt nearly every day Diminished ability to think or concentrate nearly every day Recurrent thoughts of death or suicide, with or without a plan 2./ A physical illness or reaction to the death of a loved one is not responsible for the reaction. American Psychiatric Association criteria to diagnose a manic episode include: 1./ A distinct period of abnormally and persistently elevated or irritable mood. 2./ During the period of mood disturbance, at least three of the following symptoms have persisted. Inflated self-esteem Decreased need for sleep Pressure to keep talking Racing thoughts Easily distractable Excessive involvement in pleasurable activities that have a high potential for painful consequences, (e.g., buying sprees, sexual promiscuity) 3./ Mood disturbance severe enough to cause impairment in work, social activities, or relationships, or to necessitate hospitalization to prevent harm to self or others. Criteria for diagnosing bipolar disorders, as established by the American Psychiatric Association, include: 1./ Bipolar Disorder, Mixed: Current episode involves symptoms of both manic and major depressive episodes intermixed and alternating every few days. Prominent depressive symptoms lasting at least a full day 2./ Bipolar Disorder, Manic: Currently in a manic episode 3./ Bipolar Disorder, Depressed: Has had one or more manic episode. Currently in a major depressive episode Criteria for seasonal affective disorder (SAD; depression that recurs at a particular time of year): A temporal relationship between the onset of an episode of depression and a particular 60-day period of the year. Full remissions occurring within a particular 60-day period of the year. At least three episodes of mood disturbance that have demonstrated this temporal seasonal relationship. Dysthymia, a milder form of depression, is a chronic state that lasts for years. Individuals with this disorder can suffer many of the same symptoms as depression but in a less intense way. People with dysthymia are at risk for anxiety, eating, personality, and substance abuse disorders. Symptom checklists like the Hamilton Rating Scale for Depression can be helpful to the health care professional in distinguishing "the blues" from depression (many family doctors fail to diagnose depression). People may be misdiagnosed because they present predominantly physical symptoms or may be reluctant to mention moods or feelings because of the social stigma attached to mental illness. In addition, some people do not seek help for depression because of lack of insurance coverage. Education of health care providers about diagnosis and treatment may help correct these problems. Treatment Episodes and recurrences of depression can be limited and in some cases cured with therapy. The three basic treatments are medication, psychotherapy, and electroconvulsive therapy (ECT), which are used alone or in combination, depending on the severity and duration of symptoms.
	Medications
	Antidepressant medications correct an imbalance in neurotransmitters and fall into three categories: tricyclic antidepressants, monoamine oxidase (MAO) inhibitors, and selective serotonin reuptake inhibitors. Lithium is the drug of choice for mania and bipolar disorder. The drugs are prescribed in gradually increasing dosages and may take several weeks to be effective. If there is no improvement or if side effects are a problem, a new drug may be added or substituted. Treatment generally lasts at least 6 months. Before prescribing an antidepressant drug a doctor should perform a physical exam (these medications can pose a risk for people with certain medical conditions). An infrequent but serious side effect of MAO inhibitors is sudden hypertension brought on by interaction with foods containing tyramine. This is a life-threatening state, and your doctor should provide a list of symptoms to watch for and foods to avoid. Less serious side effects may occur and should also be discussed with a doctor in an effort to find a medication that permits a good quality of life. Electroconvulsive therapy (ECT) is a safe, painless, and effective treatment for depression and bears no resemblance to the "shock therapy" of the past. During this treatment an electric current is passed through the brain and the only visible sign is twitching of the eyelids. It is used when rapid results are vital, such as with acutely suicidal patients or those in whom drug treatments have failed or cannot be administered. Treatments are generally given three times a week for 2 weeks. The only common side effect is temporary memory loss. Psychotherapy is generally used in conjunction with either ECT or medication. Many forms are available and should be tailored to individual needs. After the medication begins to take effect, psychotherapy can help the person understand the factors that contributed to the depression. For some people low self-esteem is a major issue, whereas others need to expose angry feelings. Many depressed people also benefit from making new social contacts and developing new activities.
	Home Remedies and Alternative Therapies
	Many therapies outside of medication and psychotherapy are used for treatment of depression. These alternative treatments can help treat anxiety, low self-esteem, lack of energy, and isolation. Exercise and yoga may partially relieve depression and boost confidence, perhaps by generating chemicals in the brain called endorphins, which may contribute to feelings of well-being and energy that can persist even after exercise ends. Relaxation and meditation have been shown to reduce the anxiety that may be prominent in some people with depression. Imagery techniques have been shown to boost self-esteem. In guided imagery, depressed people may be helped to envision situations in which they receive praise from someone they admire and then use the imagined praise to improve feelings of self-worth. Creative art therapies such as dance, painting, and sculpture can open communication and break down barriers when talking is too difficult for depressed people. Pet therapy, in which a person establishes a connection with another living creature, also may be helpful. Light therapy (treatment with special kinds of bright lights) has been shown to be beneficial for seasonal affective disorder.
	Male/Female Differences
	Bipolar disorder is equally common in men and women. Major depression is estimated to be twice as common in women as men.
	Suicide
	Suicide, the most dangerous consequence of depression, may be a result of the person's hopelessness or the feeling that life is not worth living. Suicidal thoughts are most common among the elderly, adolescents, men, alcoholics, and people who live alone. A family history of suicide or previous suicide attempt indicates an increased risk. A doctor should inquire about thoughts of suicide, since they are common reflections of the pain and anguish that depressed people experience. Suicidal thoughts always merit immediate and special care, with hospitalization as necessary to ensure the safety of the patient.