Simply stated, it is a feeling of sadness. Definitions of depression may vary from one culture to another. All of us may experience depression at one point in time and this is just a normal reaction to a particular event such as death of a loved one or losing a job. It becomes abnormal when it is excessive, profound and prolonged, and already affects our daily functions.

What are the symptoms of depression?

The symptoms of depression include the following:

	persistent, sad, anxious or empty mood
	feelings of hopelessness or pessimism
	feelings of guilt, worthlessness or helplessness
	loss of interest or pleasure in ordinary activities
	decreased energy, a feeling of fatigue
	difficulty concentrating or making decisions
	restlessness or irritability
	changes in appetite or weight
	unexplained aches and pains
	thoughts of death or suicide

These eventually lead to difficulties performing at work, difficulties carrying out routine activities, difficulties with home life and withdrawal from friends and social activities.

How common is major depression?

Major depression has a lifetime prevalence of 15% and this may go as high as 25% for females. In simpler terms, one out of five individuals will eventually experience a major depressive episode during their lifetime. In half of these people, there will be more than one episode. The incidence of depression is also higher in medical in and out patients, ranging from 10 to 15%.

What are the major consequences of depression if left undiagnosed and untreated?

Effects of undiagnosed depression may be divided into that resulting to patient mortality, morbidity and the cost of this illness to society. Suicide, involvement in fatal accidents due to impaired concentration and attention, and death as a result of illnesses which may be a consequence of depression (eg. Alcohol abuse) are the common causes of mortality in depressed patients. Suicide attempts, non fatal accidents, poorer physical health with resultant illnesses, lost jobs, failure to advance in career and school, and substance abuse would contribute significantly to patient morbidity. Lastly, an impact on society would come in the form of decreased productivity and quality of work, job related injuries, absenteeism and the occurrence of dysfunctional families.

What are the risk factors for developing major depression?

	Gender	Major depression is twice as likely in women
	Age	Peak age onset is from 20 to 40 years of age
	Family History	Three times higher risk with a positive family history
	Marital Status	Separated and divorced people report higher rates. Married people have lower rates than unmarried individuals
	Postpartum	An increased risk of developing depression for the 6 month period following child birth; Possible association with negative life events and early parental death

What are the common myths surrounding depressive illness and what are the actual facts to this?

	A.	Depression as well as other psychiatric disorders remain trivial. Over the years, a wealth of information through evidenced based medicine has been gathered to define, diagnose, and treat depression and other psychiatric disorders. A lot of researches have been done over the past decades especially on the biological component/etiology of depression to distinguish this illness as a distinct entity.
	B.	Depression will go away on its own and needs no treatment. Untreated depression last from 6 to 13 months with some episodes lasting more than two years. This carries a significant amount of morbidity to patient, relatives and society in general. As the course of the disorder progresses, patients tend to have more frequent episodes that last longer and are more resistant to treatment. On the other hand, most patient undergoing treatment have episodes lasting less than 3 months.
	C.	Depression is a result of character weakness. Aside from the cause of depression being unknown, no single personality trait or type uniquely predisposes a person to depression. All individuals of whatever personality type can and do become depressed under appropriate circumstances.
	D.	Depression is caused by "bad spirits." The etiology of major depression revolve around several areas such as biological, genetic, and psychosocial factors. Of these, the biological factors specifically those involving altered neurochemistry is the most consistent. No study has proven or even shown associations of "bad spirits" witchcraft with depression.
	E.	Treatment of depression remains a mystery. There are now over twenty different antidepressant belonging to one of eight pharmacologically distinct classes shown by evidence based medicine to be effective against depression. In addition several alternative and augmenting strategies to these drugs are available.

A friend just lost a loved one in his life. How will I know if this is grief or a major depressive episode?

Feeling downhearted and sad is a normal reaction to a life situation and the duration of this feeling really varies. There is usually a period of bereavement and this may last for 6 months to 1 year, depending on the culture and tradition of a particular region. Fluctuations in grief are common and even in intense grief, moments of lightheartedness and happy reminiscence are possible. Unlike grief, clinical depression persist and does not go away no matter how hard the individual tries. Shame, guilt, the feeling of hopelessness and suicidal ideations are likewise more prominent in depression.

When should a depressed patient be hospitalized?

Depressed patients are usually hospitalized if they have significant suicidal intentions or have attempted suicide presently or in the past. This is usually assessed having three factors in mind: lethality, intention and attitude. Individuals are likewise hospitalized if their depression is severe enough to incapacitate and interfere with activities of daily living such as eating etc., if significant support groups are unavailable and if there is an associated medical illness requiring treatment.

How is major depression treated and how effective is treatment?

Treatment of major depression is generally divided into the use of pharmacotherapy and the use of psychotherapy and other psychosocial therapies.

Pharmacotherapy includes the use of antidepressant medication (which are now divided into eight major classes), the use of antipsychotics for depressed patient with psychosis, and the use of ECT for patients with severe depression and who do not respond to medications. All these antidepressant medications are equally effective, they only differ in their side effects profile which is an important factor if a doctor is to prescribe medication. Different methods of psychotherapy are being used but so far Cognitive-Behavioral Psychotherapy has been effective to a lot of depressed individuals. The person needs to understand his/her experience and why he/she went into depression. Most psychiatrist favor the use of a combination of pharmacotherapy and psychotherapy in the treatment of depression.

It is a stated fact that major depression is highly treatable. The vast majority of patients (as much as 90%) respond to antidepressant medication. It is likewise important to remember that improvement takes time. Even if you already feel well after a month or two, you should try to continue taking your medicines.

Does a depressed patient have to take medicines indefinitely?

For the vast majority, the answer is No. For first time episode, treatment is for 4 to 6 months, and up to 12 months or longer for recurrent episodes. After that period, the medicine is tapered off and discontinued. Usually the first symptoms to improve are sleep and appetite. One should try to follow the prescribed schedule of intake of medication given by your doctor. It is important to remember that antidepressant medications take time to take effect and should not be discontinued abruptly. Equilibrium in the brain takes time so that is also why you need to take you medication for a longer time. You also prevent relapse when you take your medication according to the prescribed period of time.

What in general should a depressed patient do in addition to treatment?

It is first important to learn what the circumstances are that brought the condition and know what to expect particularly during the initial period of treatment. Patients need to remember that they should not blame themselves for their illness as they did not ask themselves to suffer from it. Patients should at best give themselves a reprieve from negative thinking for now. They should take their medications as prescribed, get plenty of rest, stay physically active, eat regularly, and keep socially involved. Having something to do takes your mind off the negative thoughts and channel your energies to more productive endeavors. Also, exercise helps the release of endorphins which makes us feel a sense of well being. This may be difficult for unmotivated patients so that is when the medication can help.

My doctor told me I have to undergo ECT. I am scared of this kind of treatment method because I might be injured in the process.

ECT is very effective but a lot of people would decline this kind of treatment because they think it is a very dangerous treatment modality. Usually, other medications are given to prepare a person prior to ECT so that one will not have violent convulsions while undergoing it. Done in the right manner, and with the anesthesiologist around, it is actually one of the faster and more effective way of treating depression.

What in general should a depressed patient NOT do?

A depressed patient should not drink alcohol. Alcohol causes similar changes in brain chemistry as occurs during a depressive episode. Many patients with major depression attempt to self medicate with alcohol to either help themselves sleep or to "calm their nerves". While it may initially help them fall asleep, its sedative effect wears off quickly causing early morning awakenings. Most drugs are metabolized in the liver and taking alcohol may likewise hinder or hasten the metabolism of these drugs. For the same reason, illicit drugs and other sedative or stimulating agents are not to be taken. A depressed patient should not make any major life decisions likewise especially if depression is moderate to severe.

How common is suicide in depressed patients?

One out of seven individuals with recurrent depression commits suicide. Seventy percent of patients who commit suicide have depression and would have consulted or attempted to consult a physician or counselor within 6 weeks of their attempt.

What are the risk factors for suicide?

	Sex	more than three males for every one female kill themselves. On the other hand, three females as compare to one male will attempt but not complete suicide
	Age	Suicide is age dependent and older individuals kill themselves more often than younger ones
	Depression	A depressive episode precedes suicide in up to 70% of cases
	Previous Attempts	Most people who die from suicide do so in their first or second attempt. Patients who have multiple (4+) attempts have increased risk of future attempts than suicide completion
	Ethanol use	Recent onset of Ethanol or other sedative-hypnotic drug use increases the risk of suicide

Rational thinking loss, social support deficit, presence of an organized suicide plan and verbalized suicidal ideation, absence of a spouse or close interpersonal relationships, and intercurrent medical illnesses, a family history of suicide are other factors that increase the chance of suicide.

The most important thing is to always inquire and never be hesitant to ask about suicidal ideations in a depressed patient.

Will depression recur once treated? What are the risk for future episodes of major depression?

The risk is primarily dependent on three factors: the duration of the current episode, the number of previous episodes, and a family history of major depression. The likelihood of having recurrent episodes increases if your first episode has lasted longer than two years, which is a compelling reason to treat it aggressively. The risk also increases with each subsequent episode (70% with one previous episode, 90% with two previous episodes) and with each first degree relative (parent, sibling or offspring) who suffers from major depression.

How can family and friends help the depressed patient?

The most important thing anyone can do for depressed people is to help them get appropriate diagnosis and treatment. This may involve encouraging a depressed individual to stay with treatment until symptoms begin to abate (several weeks) or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication.

The second most important thing is to offer emotional support. This involves understanding, patience, affection and encouragement. Engage the depressed patient in conversation and listen carefully. Do not ignore remarks about suicide and always report this to a doctor. Invite the depressed patient for walks , outings, to the movies and other activities. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities.