Depression

Overview

• Some signs of depression are feeling low, feeling bad about yourself and not wanting to do things.
• Depression affects different people in different ways.
• If you think you might have depression you can speak to your GP.
• Depression may be treated with medication and talking treatments. Self-help techniques, peer support groups and coping strategies can also help.
• Different things can lead to depression. Your upbringing, stressful events and your lifestyle might all have an effect.
• If you feel low, getting enough sleep and eating healthy foods might help. It might also help to keep active, even if you don’t feel like it.

About

What is depression?

Depression is a long-lasting low mood disorder. Depression is when you feel persistently sad for weeks or months, rather than just a few days. It affects your ability to do everyday things, feel pleasure or take interest in activities.

Everyone has ups and downs. Sometimes you might feel a bit low, for lots of different reasons. People may say that they are feeling depressed when they are feeling down, but this does not always mean that they have depression.

Depression is:

• a mental illness,
• common - it affects about 1 in 6 of us,
• something that anyone can get, and
• treatable.

Depression is not:

• something you can 'snap out of’,
• a sign of weakness,
• something that everyone experiences, or
• something that lasts forever.

Doctors might describe depression as 'mild', 'moderate' or 'severe'. Your doctor may offer you different treatments depending on how they describe it.

How common is depression?

Depression can affect people of any age, including children. It is 1 of the most common mental illnesses. It effects about 1 in 6 of us.

The number of people who have depression may be higher than this because not everyone with depression goes to their GP.

Diagnosis & symptoms

What are the symptoms of depression and how is it diagnosed?

The NHS recommends that you should see your GP if you experience symptoms of depression for most of the day, every day, for more than 2 weeks.

Doctors make decisions about diagnosis based on manuals. The manual used by NHS doctors is the International Classification of Diseases (ICD-10).

When you see a doctor they will look for the symptoms that are set out in the ICD-10 guidance. You do not have to have all of these to be diagnosed with depression. You might have just experience some of them.

Some symptoms of depression are:

• low mood, feeling sad, irritable or angry,
• having less energy to do certain things,
• losing interest or enjoyment in activities you used to enjoy,
• reduced concentration,
• becoming tired more easily,
• disturbed sleep and losing your appetite,
• feeling less good about yourself (loss of self-confidence), or
• feeling guilty or worthless.

You may also find that with low mood you:

• feel less pleasure from things,
• feel more agitated,
• lose interest in sex,
• find your thoughts and movements slow down, and
• have thoughts of self-harm or suicide.

Your doctor should also ask about any possible causes of depression. For example, they may want to find out if you’ve experienced anything traumatic recently which could be making you feel this way.

There are no physical tests for depression. But the doctors may do some tests to check if you have any physical problems. For example, an underactive thyroid can cause depression.

On the NHS website, they have a self-assessment test which can help you to assess whether you are living with depression: www.nhs.uk/mental-health/conditions/clinical-depression/overview/

Types & causes

What are the different types of depression?

You might have heard a number of terms used to describe depression. In this section, we explain what some of these terms mean.

What is clinical depression?

Clinical depression is a common term, but it is not a formal diagnosis. People sometimes say ‘clinical diagnosis’ to just mean they have been diagnosed by a doctor.

What is a depressive episode?

Your doctor might say that you are going through a 'depressive episode'. This is the formal name that doctors give depression when they make a diagnosis. They may say that you are going through a 'mild', 'moderate' or 'severe' episode.

What is recurrent depressive disorder?

If you have had repeated episodes of depression, your doctor might say that you have recurrent depressive disorder. They may say that your current episode is 'mild', 'moderate' or 'severe'.

What is reactive depression?

If your doctor thinks that your episode of depression was caused by particular stressful events in your life, they may say that it is reactive. For example, divorce, job or money worries. This is sometimes separated from an adjustment disorder, where you may struggle with some symptoms of depression because of adapting to a major change in your life. Such as separation from people, retirement or migrating to a new area.

What is a severe depressive episode with psychotic symptoms?

If you are going through a severe episode of depression, you may experience hallucinations or delusions. A hallucination means you might hear, see, smell, taste or feel things that others cannot. A delusion means that you might believe things that don’t match reality. These symptoms are called psychosis.

You can find more information about ‘Psychosis’ by clicking here.

What is dysthymia?

Your doctor might diagnose you with dysthymia if you have felt low for several years. But the symptoms aren’t severe enough, or the episodes aren’t long enough for a doctor to diagnose recurrent depressive disorder.

What is cyclothymia?

Your doctor might diagnose cyclothymia if you struggle with persistently unstable moods. You might have several periods of depression and periods of mild elation. These periods of depression or elation are not severe enough or long enough to diagnose recurrent depression or bipolar disorder. Cyclothymia is more commonly associated with bipolar disorder than depression.

What is postnatal depression?

Post-natal depression is a type of depression that many parents experience after childbirth. It is a common illness, which affects more than 1 in every 10 women within a year of giving birth. The partner can also experience postnatal depression. You may get symptoms that are similar to those in other types of depression.

What is seasonal affective disorder (SAD)?

SAD affects you at the same time of year, usually in the winter. Some people may find they have symptoms in summer and feel better in winter. The symptoms are similar to depression. But some people find they sleep more rather than less, and crave carbohydrates like chocolate, cakes and bread. SAD can sometimes run-in families.

What is manic depression?

Manic depression is the old name for bipolar disorder. It is a different illness to depression. People with this illness have highs (mania) and lows (depression).

You can find more information about ‘Bipolar Disorder’ by clicking here.

What causes depression?

There is no single cause of depression. Different things may cause depression for different people. This section looks at some of the things that might cause depression, or depressive symptoms.

Can depression be inherited?

There is not a clear pattern to suggest that depression can be inherited. Some studies suggest that your genetics can play a part in developing depression. For example, 1 study found that particular genes may play a key role in developing recurrent depression.

Some researchers have suggested that people who have a parent or sibling with depression, have a 2 to 3 times more chance of developing depression. However, just because a relative lives with depression, it does not mean you will too.

Can my background or current situation cause depression?

Researchers have looked at whether having parents or other family members with depression can increase your chances of developing the condition. For example, a study has looked into the effects having a mother with postpartum depression can have on children as they grow up.

Research has also suggested that stressful events, such as problems at home or work, a relationship ending or financial issues may also make it more likely you will get depression.

Can my hormones or the chemicals in my body cause depression?

Changes in your hormones and chemicals in your body may cause depressive symptoms.

For example, at some point many women might find their mood is affected in the weeks before their period, called pre-menstrual syndrome (PMS). Some women may struggle with premenstrual dysphoric disorder (PMDD). PMDD is similar to depression, and has similar symptoms of PMS, but the symptoms are more severe.

Having problems with your thyroid or having low levels of Vitamin B12 may also be linked to feeling symptoms of depression.

How can lifestyle factors affect depression?

Some studies have shown that not exercising, being under or overweight can increase the risk of experiencing depressive symptoms The risk can also be increased by having fewer social relationships.

Can drugs and alcohol affect my mental health?

Both legal and illegal drugs might affect your mental health. If you take prescribed medications, it is important to make sure you take them in the way your doctor suggests.

Some people will drink alcohol because it feels like it can relieve anxiety or depression. However, the evidence suggests that if you drink regularly or misuse alcohol you are at a greater risk of developing depression.

You can find more information about ‘Drugs, alcohol and mental health’ by clicking here.

Can other illnesses impact my mental health?

Depression can come with other mental or physical health conditions such as such as diabetes or cancer. Medication taken for these conditions may cause side effects which may trigger depression for some people.

Some people with brain injuries and dementia may also have changes in their moods.

You can find more information on looking after your physical health in our ‘Good health guide’ at www.rethink.org. Or call our General Enquiries team on 0121 522 7007 and ask them to send you a copy of our factsheet.

Treatment

How is depression treated?

The first step to getting treatment is to see your GP. If your GP thinks you have depression, they will talk to you about the treatments they can offer.

What are talking therapies?

Talking therapy is a general term to describe any psychological therapy that involves talking. You may also hear the terms counselling or psychotherapy used to describe talking therapy.

Therapy should offer you a safe, confidential place to talk about your life and anything confusing, painful or uncomfortable. It allows you to talk with someone who is trained to listen attentively and to help you improve things.

Talking therapy often takes place face to face. But you may also be able to have therapy over the phone, by video call or online. There are different types of talking therapy that you might be offered. These include:

• cognitive-behavioural therapy,
• psychodynamic therapy,
• problem-solving therapy,
• interpersonal therapy,
• behaviour activation,
• group therapy,
• relationship counselling,
• eye movement desensitisation reprocessing,
• mindfulness based therapy, and
• counselling.

The type of therapy you are offered will depend on the cause of your symptoms and their severity. Therapies may also have different levels based on how long or intense the treatment is.

Ask your GP about therapy if you think it might help. Some of these therapies will be available in your area. Some areas offer a self-referral option for NHS talking therapies. Please refer to your local Improving Access to Psychological Therapies (IAPT) service to find out about this option.

You may also be able to access therapy privately or through your employer in an Employee Assistance Programme.

When you finish treatment, your doctor may suggest Mindfulness Based CBT (MCBT) which can be helpful if your depression comes back. MCBT combines mindfulness techniques like breathing exercises and meditation with CBT. The National Institute of Health and Care Excellence (NICE), recommend individual CBT or MCBT for people who struggle with their depression coming back, or relapsing.

What is Computerised cognitive behavioural therapy (cCBT)?

Computerised cognitive behavioural therapy (cCBT) is one way of treating mild to moderate depression. You learn CBT techniques online using a computer. You will go through the same type of session as you would if you were with a therapist. It can be helpful after you have finished talking therapies to stop your symptoms coming back.

How can antidepressants help?

Your doctor might offer you an antidepressant. You may need to try different types before you find one that works for you. If you do not want to take antidepressants, tell your doctor and you can discuss other options.

Antidepressants can have side effects and can affect other medicines you are taking. Your doctor will check if you have physical health conditions or if you take other medication.

It is important to talk to your doctor before you stop taking medication, because stopping suddenly can cause problems.

How can exercise help?

Regular exercise can help with your mood if you struggle with depression. Some GP surgeries will put you in touch with local exercise schemes. This is sometimes called ‘exercise on prescription’ and can give you access to free or reduced cost programmes.

What is electroconvulsive therapy (ECT)?

Electroconvulsive therapy (ECT) is a procedure sometimes used to treat severe depression. In this treatment, an electrical current is briefly passed through your brain while you are under general anaesthetic. This means you are not awake during the procedure. You should only have ECT if you have severe depression, it is life-threatening and treatment is needed as soon as possible. Or you may be given ECT if no other treatments have worked.

What types of brain stimulation treatments are available for depression?

There are 2 types of brain stimulation treatments available. Please see below.

Transcranial direct current stimulation (tDCS)
This treatment involves using a small battery-operated machine to pass a low current through your brain to stimulate activity. You are awake during the procedure, with daily sessions for several weeks. NICE state that there is not a lot of evidence for how tDCS works for depression, but there are no major safety concerns.

Repetitive transcranial magnetic stimulation (rTMS)
rTMS uses electromagnetic coils to deliver pulses of magnetic energy to specific parts of your brain. This stimulates the brain and may help to reduce depression and anxiety. You are awake during the procedure and can leave hospital the same day. If this is offered, you may have daily sessions for several weeks. NICE have examined rTMS and found that it is safe and effective enough to be offered on the NHS.

How can complementary or alternative therapies help depression?

Complementary therapies are treatments which are not part of mainstream healthcare. They can include aromatherapy, herbal remedies, acupuncture, massage, meditation and yoga. These treatments may help improve your emotional wellbeing and may help with side effects.

You can find more information about:

• Antidepressants by clicking here.
• Talking Therapies by clicking here.
• Electroconvulsive Therapy (ECT) by clicking here.
• Complementary and alternative treatments by clicking here.

What treatment should I be offered?

The National Institute of Health and Care Excellence (NICE) writes guidance on what treatment doctors should offer you. But your doctor does not have to give you these treatments. And the treatments may not be available in your area.

Different treatments may be available in your area. Your doctor might think these suit your symptoms more than the recommended treatments.

NICE recommend that depression is treated in different steps depending on how severe the condition is for you. The steps are as follows.

Step 1: Everyone who may have depression

Your doctor should offer you:

• an assessment of your symptoms,
• support, such as regular appointments in person or by telephone,
• information on how to deal with your symptoms,
• monitoring of your symptoms and follow-up, and
• referral for further assessment and treatment if needed.

Step 2: Mild to moderate depression

Your doctor may offer you:

• low-intensity interventions, such as self-help guided by the doctor or computerised cognitive behavioural therapy (cCBT),
• physical activity programmes,
• group cognitive behavioural therapy (CBT),
• medication if you have a history of moderate or severe depression, or you have had symptoms for a long time, and
• referral for further assessment and treatment if needed.

Step 3: Moderate to severe depression, or mild to moderate depression when other treatments haven’t worked

Your doctor may suggest:

• medication,
• higher intensity therapy such as individual CBT or behavioural activation,
• combined treatments of both medication and therapies,
• support from different teams if you need it, and
• referral for further assessment and treatment if needed.

Step 4: Severe and complex depression or if your life is at risk Your doctor may suggest:

• medication,
• high-intensity talking therapy,
• electroconvulsive therapy (ECT),
• crisis services,
• combinations of different treatments,
• support from different teams if you need it, and
• hospital treatment in emergencies.

Problems

What if my symptoms don’t improve?

If you’re not responding to treatment, you may live with treatment resistant depression. This is when your symptoms have not improved after at least 2 standard treatments. This can also be known as treatment-refractory depression.

There is currently no official criteria used to diagnose treatment resistant depression.

What treatment is available for treatment-resistant depression?
There are treatment options for treatment resistant depression. Even if antidepressants have not worked already for you, your doctor may suggest a different antidepressant from a different class.

The new antidepressant you are offered will depend on the first antidepressant you were given.

Sometimes your doctor can prescribe a second type of medication to go with your antidepressant. This can sometimes help the antidepressant work better than it does by itself.

Where antidepressants have not worked, your doctor may suggest talking therapies, ECT or brain stimulation treatments. See the previous section for more information on these.

What is an implanted vagus nerve stimulator, and how is it used in treatment resistant depression?
If you live with treatment resistant depression, and you’ve not responded to other treatments, you may be able ask for an implanted vagus nerve stimulator.

This is given for treatment-resistant depression to reduce symptoms with the aim of improving mood by regular stimulation of the vagus nerve. However, there is not currently a lot of evidence about how well this procedure works for treatment-resistant depression.

Please speak to your doctor if you’re interested in this treatment and for more information. You may be able to get this treatment funded through an ‘Individual Funding Request’.

For more information, please see our factsheet:

• NHS - Your Rights by clicking here.

What if I am not happy with my treatment?

If you are not happy with your treatment you can:

• talk to your doctor to see if they can suggest changes,
• get an advocate to help you speak your doctor,
• ask for a second opinion if you feel it would help,
• contact Patient Advice and Liaison Service (PALS) and see whether they can help, or
• make a complaint.

There is more information about these options below.

Advocacy

An advocate is independent from the NHS. They are free to use. They can be useful if you find it difficult to get your views heard.

There are different types of advocates available. Community advocates can support you to get a health professional to listen to your concerns. And help you to get the treatment that you would like. They aren’t available in all areas.

You can ask an advocate to help you make a complaint. Advocates that do this are called NHS complaints advocates. They are free to use and don’ t work for the NHS. They’ re available in all areas.

You can search online to search for a local advocacy service. If you can’t find a service you can call our advice service 0808 801 0525 (Monday to Friday, 9.30am-4pm, excluding bank holidays). You can email us too at advice@rethink.org. We will look for you.

Second opinion

Talk to your doctor about your treatment to see if you can resolve the problem with them first. If you don’t agree with their decisions about diagnosis or treatment, you could ask for a second opinion. You are not legally entitled to a second opinion, but your doctor might agree to it if it would help with treatment options.

'PALS'

The Patient Advice and Liaison Service (PALS) at your NHS trust can help to resolve problems or issues you have with an NHS service. You can find your local PALS’ details at www.nhs.uk/Service-Search/Patient-advice-and-liaison-services-(PALS)/LocationSearch/363.

Complaints

It is best to try and solve the problem with the team or doctor first. If this does not help you can make a formal complaint. If you are unhappy with their response to your complaint, then you may be able to take this up to the Parliamentary and Health Service Ombudsman.

You can get an Independent Health Complaints Advocate (IHCA) to help you make a complaint against an NHS service.

You can find more information about:

• Advocacy by clicking here.
• Second opinions by clicking here.
• Complaints by clicking here.

Self-care & risks

What self-care and management skills can I try?

You can learn to manage some of your symptoms by looking after yourself. Self-care is how you take care of your diet, exercise, daily routine, relationships and how you are feeling. You will learn how to notice when you are becoming unwell and know what your triggers are.

How can my diet affect my mood?

Our diet affects our physical health. Depending on what you eat you could develop problems like obesity, heart disease and diabetes. In the same way, the things we eat may affect our moods and mental health.

Some people deal with their depression by eating high-fat and high-sugar foods. Also, seasonal affective disorder (SAD) can make you crave sugary carbohydrates like cakes and biscuits.

To manage your diet you can:

• eat regular meals,
• eat a healthy balance of fat and reduce the amount of trans-fat you eat,
• eat fruit, vegetables and wholegrains,
• eat oily fish such as salmon, mackerel, herring or trout,
• drink 6-8 glasses of water per day,
• limit your caffeine in drinks such as tea, coffee or fizzy drinks, and
• limit the amount of alcohol you drink.

The UK Chief Medical Officer recommends that men and women should not regularly drink more than 14 units of alcohol a week. This is to help keep the risks and affects from alcohol low.

If you have depression, making these changes may not have an instant impact on your mood. However, they can be important for long-term recovery.

How can exercise help my mood?

Exercising regularly can help your mood. You can exercise any way you like, so long as it safely increases your heart rate and makes you breathe faster. Exercise can also help if you have problems sleeping. Getting proper sleep may be important for your mental health.

How much you can do depends on your age, physical health and fitness. If you do not exercise already, start with small amounts and fit this into your daily routine. You can then slowly increase the amount you do. This approach may help with your motivation.

There are programmes like the NHS’s Couch to 5KM where they gradually help you go from doing no exercise to walking. Or jogging for 5 kilometres. Some other ideas are listed below.

• Going for a walk: You could get a pedometer or an app that counts your steps. Slowly challenge yourself to walk more steps and reach a goal. Some people challenge themselves to walk 10,000 steps a day.
• Cycling: Make sure you wear a helmet and high visibility vests or chest strap. Stick to quiet roads if you aren’t confident on a bike.
• Gardening: There may be a local NHS or charitable gardening scheme in your area. Ask your GP, volunteering services or social services. You can check your area on ‘The Conversation Volunteers’ website to see if there are any projects in your area. Their details are in Useful Contacts at the bottom of this page.
• Jogging: Try jogging around the block to start with. Then slowly increase the amount of time you jog for, or the distance you go.
• Playing a sport: Try speaking to friends or family to see if they will join you in a sport. Or join a local club. You could also look at individual sports.
• Gym: As well as indoor gyms, there are free ‘green gyms’ all across the country. See ‘The Conversation Volunteers’ website for more details in the Useful Contacts section at the bottom of this page.
• Housework: Doing housework in an active way can be good exercise.

Some mental health medication can cause problems with weight gain. Exercise could also help you manage this. To help, you could look at the NHS 12-week diet and exercise plan which you can find here:
www.nhs.uk/live-well/healthy-weight/start-the-nhs-weight-loss-plan/

You should speak to your doctor if you have any concerns about gaining weight due to medication. You should also speak to your doctor if you have any concerns before starting to exercise.

What risks and complications can depression cause?

Having depression can cause other problems. It can affect your mental health as well as your physical health, and it may affect other areas of your life too. For example, depression may cause:

• disturbed sleep,
• aches and pains,
• low sex drive,
• difficulties with work and your hobbies,
• difficulties keeping contact with friends and families, or
• suicidal thoughts or thoughts of self-harming.

Some people might also drink more alcohol to try and relieve depression. However, as we said in the previous section above, this can actually make depression worse.

If you have any of these problems, speak to your GP.

Family, carer's and friends

Information for family, carers and friends

You can get support if you are a carer, friend or family member of someone living with depression.

Being a carer might mean you can claim certain benefits that might help you and the person you care for. For more information, please see the Mental Health and Money Advice services website:
www.mentalhealthandmoneyadvice.org/en/welfare-benefits/what-benefits-are-available-for-mental-health-carers/

You could also get in touch with carer support groups or sibling support groups. You can search for local groups in your area online or ask your GP.

You can ask your local authority for a carer’s assessment if you need more practical support to help care for someone.

As a carer you should be involved in decisions about care planning. There are rules about information sharing and confidentiality which may make it difficult for you to get all the information you need in some circumstances.

You can find out more information about:

• Carer’s assessments by clicking here.
• Confidentiality and information sharing by clicking here.

How can I support the person that I care for?

You might find it easier to support someone with depression if you understand their symptoms, treatment and self-management skills. You can use this to support them to get help and stay well.

Below are some initial suggestions for providing practical day to day support to someone with depression.

• Offer them emotional support by being a good listener, reminding them that treatment is available and reassuring them. Remember that depression is an illness and people cannot “snap out of it”.
• Encourage them to get some exercise and eat healthily. You could invite them out on walks, or help them do things they used to enjoy.
• Keep a note of changes in their medication, or their condition. This can help the person you care for in appointments.
• Help them to stay away from alcohol and other unhealthy things.
• Take them seriously if they are feeling very unwell and are thinking about hurting themselves. Encourage them to get professional help.

You could also try and find out about self-help or support groups in their area. Your local IAPT service may be a good place to start.

Think about what you can do if you are worried about someone’s mental state or risk of self harm. It will help to keep details of their mental health team and discuss a crisis plan with them.

You can find out more information about:

• Supporting someone with a mental illness by clicking here.
• Getting help in a crisis by clicking here.
• Suicidal thoughts – how to support someone by clicking here.
• Responding to unusual behaviour by clicking here.

Further reading

You can find more information about:

• Bipolar Disorder by clicking here.
• Psychosis by clicking here.
• Drugs, Alcohol and Mental Health by clicking here.
• Antidepressants by clicking here.
• Talking Therapies by clicking here.
• Electroconvulsive Therapy (ECT) by clicking here.
• Complementary Therapies by clicking here.
• Advocacy by clicking here.
• Second opinion by clicking here.
• Medication – Choice and managing problems by clicking here.
• Complaints about the NHS and social services by clicking here.

Counselling Directory
This website has lots of information about depression and other self-help resources.

Website: www.counselling-directory.org.uk/depression.html

Northumberland, Tyne and Wear NHS Foundation Trust
This NHS trust has produced a self-help guide for Depression and Low mood.

Website: www.web.ntw.nhs.uk/selfhelp/

Overcoming
This website has information on self-help guides you can buy for a range of different conditions. They are not free resources but can read reviews of different books here. You may be able to get some of the books cheaper if you buy them second hand.

Telephone: 0720 3122 7000
Email: overcoming@littlebrown.co.uk
Website: www.overcoming.co.uk

Online cognitive behavioural therapy (CBT) resources
This website is from the NHS. It has a selection of different resources that can help with depression.

Website: www.nhs.uk/conditions/stress-anxiety-depression/pages/low-mood-stress-anxiety.aspx

Useful contacts

Mood Swings Network
This service provides a range of services for people affected by a mood disorder such as depression, including their family and friends.

Telephone: 0161 832 3736
Address: 36 New Mount street, Manchester, M4 4DE.
Email: info@moodswings.org.uk
Website: www.moodswings.org.uk

The Conservation Volunteers
This organisation helps people to get involved in local conservation projects and has Green Gyms.

Telephone: 01302 388 883
Address: The Conservation Volunteers, Sedum House, Mallard Way, Doncaster, DN4 8DB
Email: information@tcv.org.uk
Website: www.tcv.org.uk

Do-it
This is an organisation that supports people to get into volunteering across the country.

Website: www.do-it.org/

Pandas Foundation
This organisation provides advice and support for people struggling with pre- and post-natal depression.

Telephone: 0808 1961 776
Address: The Fort, Artillery Business Park, Park Hill, Oswestry, SY11 4AD.
Email: info@pandasfoundation.org.uk
Website: www.pandasfoundation.org.uk

Cruse Bereavement Care
This organisation provides support for people struggling with bereavement. They offer support by telephone and in local centres across the country.

Telephone: 0808 808 1677 (Monday and Friday 9.30am - 5pm, Tuesday, Wednesday & Thursday 9.30am - 8pm, Weekends 10am - 2pm)
Email: helpline@cruse.org.uk
Website: www.cruse.org.uk