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WHAT IS IT?
We all feel a bit blue once in a while, perhaps after a loss or setback, during an illness, or when we’re under a lot of stress. Such moods are normal, and they pass with time.

But sometimes those feelings don’t go away. Instead, they become a stubborn sorrow that can last for weeks or months at a time, or comes and goes for no clear reason. This is the illness that doctors call depression.More than 19 million Americans suffer from depression. It can occur at any age, though it tends to be more common at certain life stages, such as the late teen years and old age. It’s much more common in women than in men.

People who are depressed have a hard time enjoying life or feeling pleasure. They may have problems with work, relationships, or even the simple tasks of daily living. A severely depressed person may think of suicide.

Depression is not a sign of weakness, laziness, or lack of willpower. It is an illness that can be treated. The good news: Most people who become depressed find that it does go away. And even when it won’t go away, people learn to manage their illness, just as people with diabetes or high blood pressure manage theirs. You can do a lot to keep depression in check. And if you do become depressed, you can do a lot to speed your recovery.
WHAT IS HAPPENING?
Depression is a complex problem. Most experts think it’s linked to two sources: our emotional reactions to a life event such as a loss, and to changes in brain chemistry. They believe that people who become depressed as a result of a life change, or who tend to get depressed for no clear reason, may not have enough of certain brain chemicals that affect mood.

The body’s nervous system and its command center, the brain, are a network of billions of nerve cells called neurons. Every time a nerve impulse moves from one neuron to the next-much like an electric current-it crosses a point called a synapse. Chemicals called neurotransmitters help impulses move from cell to cell so we can think, feel, and do all the other things we do to live.

There are many kinds of neurotransmitters. Depression seems to be linked to low levels of at least two of them: serotonin and norepinephrine. These appear to play a role in how alert or anxious we feel. But experts don’t yet know whether the changes in brain chemistry are the result of depression or the cause of it.
WHAT CAUSES IT?
While we still have much to learn about the workings of emotions and the brain, we do know that a number of factors can increase a person’s risk of becoming depressed. Some of these-such as your gender and family background-are beyond your control. But you can do plenty about other risk factors, such as your exercise habits, the amount of stress in your life, and the medicines you take.

THINGS YOU CAN’T CHANGE

Being a woman
Women are twice as likely as men to become depressed. Scientists have been unable to uncover convincing evidence that genes or hormones cause the difference, although some think that estrogen plays a role in mood. Some experts also think there’s a possible cause in the way women are treated as children. Girls may be less likely than boys to grow up with a sense of independence, mastery, and self-esteem, and as a result they may be more inclined to depression. Also, the hormonal changes that take place following childbirth can cause temporary depression, which may account for some of the difference in numbers (see “Types of Depression,” below).

Age
Adolescents, the middle-aged, and men and women past retirement have a higher risk of depression than others. All of these life stages tend to involve big changes and extra stress, which can trigger depression in some people.

Family background
Depression seems to run in some families. People may become depressed because of family stress or traumas. Some people may become depressed as adults because of problems they had when they were children, such as abuse or loss of a parent. Also, problems with neurotransmitters that affect mood may be passed from parent to child.

Illness
Any illness can trigger depression in someone who tends to get depressed. But some illnesses can cause depression directly: An underactive thyroid is a common physical cause. The thyroid is a gland that makes many hormones we need for good health. Among them are those that help control moods. When the gland doesn’t make enough, the body’s metabolism slows down and a person can become lethargic and depressed.

Loss
People who have suffered a major loss or setback in life are at risk of depression. The loss might come from “outside”-the loss of a friend or loved one. Or it might come from “inside”-a loss of self-esteem or one’s hopes for the future.

THINGS YOU CAN CHANGE

Emotional support
Depression often strikes those who are isolated and lonely, above all when they suffer a loss such as the death of a friend or loved one.

Exercise
Studies show that people who don’t exercise are more likely to be depressed than those who are more active. Exercise can also ease symptoms in people who are depressed. Scientists think that exercise raises levels of neurotransmitters that boost mood.

Medications
Some medications-for instance, those used in hormone replacement therapy and treatment for blood pressure-can cause depression.

Substance abuse
Some people try to combat low moods by using alcohol or drugs. But these substances don’t help. Instead, they can cause depression or make it worse.
WHAT YOU CAN DO FOR YOURSELF
You can do a lot to avoid depression by making smart choices about exercise, easing stress, and getting emotional support in times of crisis. If you are depressed, you can help yourself feel better by making these same choices.

Reach out for support
When you feel low, keep in touch with friends and members of your family. Just talking can help. Tell them how you feel; it really helps to know someone is listening to you. As you talk, you may even think of some ways to ease the crisis.

Try a support group. There are many kinds of groups, such as those for adult children of alcoholics, survivors of abuse, or people who are grieving. It’s important to get support from people who know what you’re going through and can thus treat you with respect and understanding.

If a depressed friend or loved one comes to you, you can help by just listening. Don’t make judgments or offer a lot of advice; you could end up irritating the person and making matters worse.

Exercise
Try to exercise for at least 20 to 30 minutes three to five days a week, or whenever you feel down. It will help. Pick an activity that makes you sweat a bit and gets your heart rate up. Walking, running, bicycling, and swimming are all ideal. Pick something you enjoy. Also, exercise outdoors as much as you can. Many people find they feel better when they get out in sunlight.

Take care of your health
Be sure to eat balanced meals and get enough sleep-but not too much-when you feel low. You’ll be able to handle stress more easily that way.

Don’t abuse drugs or alcohol
If you drink alcohol, don’t drink much. Alcohol is a depressant. A rule of thumb for men is no more than two drinks a day; for women, no more than one. A “drink” is one 12-ounce can of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits. Never have more than one drink in an hour. And stay away from all illegal drugs.

Ease stress
Too much stress can trigger depression in some people. While no one can avoid stress all the time, there are ways to cope with it. For instance:

Take time out to do things you enjoy, such as reading a book you like or taking a walk. Plan outings with friends. Take breaks during a hectic day to calm down-aim for at least a 20-minute time-out twice a day.
If you’re feeling upset about problems in your life, try writing about them in a journal. It helps.
Try meditation. Studies show it can relieve stress. Here’s an exercise to start:
Find a quiet place where you won’t be disturbed for 20 minutes. Sit in a chair with your feet on the floor and your hands in your lap. Close your eyes and in your mind say a simple word or phrase. Try the word one. When thoughts come to mind, ignore them and return to the word. Make it the focus of your attention, but don’t force it or work at it-let it come as though you are hearing it, not thinking it. As you relax, you may slump over or even drift briefly into sleep. Don’t worry, just allow yourself to let go. Practice this once a day (twice is better) for lasting results. If you don’t have 20 minutes, try ten.

Check your medications
If you’re taking a medicine that you think may be causing your depression, talk to your doctor about switching to another. Never stop taking any medication, though, without talking with your doctor first.
WHAT YOUR DOCTOR CAN DO FOR YOU
Your doctor may give you a physical exam or order some lab tests to make sure your depression isn’t caused by an illness, such as an underactive thyroid, that needs to be treated. If the self-care ideas above haven’t helped, your doctor can suggest a number of treatment options:

Psychotherapy
Psychotherapy-”talk therapy”- often helps relieve symptoms of mild depression. It may help you change ways of thinking and behaving that cause your depression or make it worse, such as feeling you’re no good. Your therapist may ask you to keep a journal to record your feelings, or to reach out to friends when you’re depressed. The therapist may also suggest ways you can improve your relationships with others-suggesting, for instance, that you talk more with your partner about what troubles you. You don’t always have to work one-on-one with a therapist-you might find that talking to others in a support group or family therapy can help, and the others in your group may express feelings and experiences that provide useful insight into your own situation.

The three types of therapists are psychiatrists, psychologists, and psychoanalysts. A psychiatrist is a medical doctor who treats mental illnesses with psychotherapy and also drugs. Psychologists and psychoanalysts treat mental illnesses with psychotherapy, but they can’t prescribe drugs. Social workers and psychiatric nurses may also practice psychotherapy. Your doctor can help you decide if you need a therapist, and which type will be best for you.

Medications
The medicines used to treat depression work by changing levels of brain chemicals-such as serotonin-that affect mood. They affect people in different ways, though, and they all have side effects: results that go beyond the changes they’re designed to produce. If your doctor decides a drug would help, you may need to try more than one to find the drug that works best for you, with the fewest side effects.

SSRIs
These are the most common antidepressants. SSRIs (selective serotonin reuptake inhibitors) keep the brain chemical serotonin from moving into nerve endings; the serotonin stays in the spaces around the nerve ends, which seems to help improve mood. Some well-known SSRIs are Paxil, Prozac, and Zoloft. Common side effects of SSRIs are trouble sleeping and loss of sexual desire. Two other antidepressants, Effexor and Serzone, affect two neurotransmitters, serotonin and norepinephrine.

Heterocyclic antidepressants (HCAs)
Also known as tricyclics, HCAs enhance the effects of serotonin as well as norepinephrine. Side effects of heterocyclics such as Elavil include dry mouth, weight gain, and dizziness or drowsiness. Remeron (mirtazapine) has a slightly different chemical structure from the HCAs, but has a similar effect. It may also have fewer side effects than the HCAs.

Monoamine oxidase inhibitors
These drugs are often used when others don’t work. They can cause severe side effects, such as dangerous rises in blood pressure, when combined with alcoholic beverages or with foods such as aged cheese, which contain a substance called tyramine. Other side effects include dizziness, insomnia, and impotence. Newer MAOIs, including selegiline and moclobemide, do not require you to avoid foods containing tyramine.

Saint-John’s-wort
For years, the herb called Saint-John’s-wort (Hypericum perforatum) has been a folk treatment for depression. Now a number of studies of patients who use the herb confirm that it is as good as antidepressant drugs at easing mild depression, and has fewer side effects.

We still don’t know about long-term effects, however, and some studies show that it can interact dangerously with certain drugs such as indinavir, a drug used to treat HIV infection, or cyclosporine, which is taken by patients who have had an organ transplant. Also, many of the studies were small and not well-controlled, and they compared the herb to older drugs, not today’s more effective treatments.

If you want to try Saint-John’s-wort, check with your doctor first, especially if you take other drugs. Don’t combine the herb with prescribed antidepressants, and be aware that your skin may become more sensitive to sun exposure.

Therapy and drugs
New studies show that a combination of antidepressants and psychotherapy work better for some people than either treatment alone. Others give evidence that psychotherapy may be just as useful as drugs for some people. You may have to experiment with different treatments to see what works for you.

Electroconvulsive therapy
Doctors use electroconvulsive therapy for the most severe depressions, and only as a last resort. The patient gets an anesthetic and a muscle relaxant, then an electric shock to the brain. You don’t feel any pain. Most people who have this treatment report brighter moods afterward. A major side effect is temporary memory loss-many people who get the therapy find they have a hard time recalling events that happened just before and after treatment, but earlier memories return to normal after just a few moments.

Electroshock treatment was often misused in the 1940s and 1950s. It’s given in a much milder form today than it was then. Though researchers can’t explain exactly how it works, it remains an effective treatment for severe depression and for patients who can’t tolerate the side effects of medications.