Depression: causes, treatment, prognosis
What is depression?
A depression is expressed by the appearance of a depressed, sad mood, which is accompanied by lack of interest and joylessness as well as a significant reduction in drive. By definition, these symptoms persist over a period of more than two weeks, can not be influenced by external stimuli, and severely limit the life of the person concerned. Everyone knows sad days and cloudy moods. But not everyone who experiences sadness or suffers from grief is immediately depressed. In contrast to a true depression, these moods are often due to a specific life event, can be actively influenced and disappear again as soon as the triggering cause has been resolved or the reason for the grief has been processed.
Typical: can not feel anything anymore
In depression, however, a "feeling of numbness" is often described. This feeling is very typical of a "real" depression. It expresses itself through the inability to feel feelings of any kind. Furthermore, in depression, apart from the sad mood, the following symptoms often occur:
- concentration problems
- sleep disorders
- Decreased self-esteem
- No desire for sex, libido loss
- No appetite
- Gastrointestinal complaints
- Weight changes.
The hard way to the doctor
Many sufferers suspect that they have depression, but do not go to the doctor for a long time. This has a lot to do with the fact that mental illness is still strongly stigmatized. But depression is everything but alone. Depression is now one of the most common diseases in Germany. And more importantly, in particular, if it is recognized and accepted early on, depression can usually also be treated well.
The treatment of depression depends on the severity of the disease: While mild depression can be treated by talk therapy and other methods of psychotherapy alone, severe depression usually involves a combination of medication and psychotherapy.
Causes of depression
Our 10 most important tips against depression
Only rarely can depression be attributed to a single cause. There are usually several factors that work together to cause depression. Doctors speak here of a multifactorial genesis or a bio-psycho-social model of disease development. It means that different genetic and physical as well as psychological and psychosocial influences interact and thus cause the onset of depression. As a result, not every depression can be treated the same way. This makes clear how important the identification of individual causes can be.
Different studies show that a certain predisposition to depression is passed on through the genes. Which are, however, is still largely unknown. However, this explains the accumulation of the disease in some families. For example, if you have a first-degree relative with depression, you have a 25-30% risk of developing depression. In the general population, the lifetime risk is estimated at 10-15% depending on studies and sources.
In many cases of depression, at the same time as the onset of the disease, certain neurotransmitters in the brain become depleted. It is certain that a reduced concentration of norepinephrine, Dopamine and above all serotonin is directly related to the onset of depression. However, it is not clear who the hen is and who the egg is. Does the neurotransmitter metabolism get mixed up and then it goes badly, or is it for very different reasons bad and then serotonin & Co are inhibited. The fact is: the neurotransmitters are responsible for the communication of nerve cells in the brain. They are also responsible for the processing of impressions, but also for the development of feelings. A deficiency can therefore lead to an imbalance and thus to emotional poverty, which is reflected in depression. A special case is depression caused by serious illnesses such as cancer or pain.This is referred to as secondary depression, which usually develops reactively in the course of incomplete treatment of the disease.
Psychic & psychosocial causes
Various studies have shown that negative and chronic stress can lead to depression. Stress is a very broad concept: while some people are stressed by their everyday work, stress for others is associated with a stressful family situation, a physical trauma or a chronic illness. The body reacts to stress by releasing the hormone cortisol. This serves in the short term the mobilization of reserves and helps to deal with a stressful situation. However, prolonged increases in cortisol levels can cause discomfort such as depression. From this observation, an association between cortisol imbalance and the onset of depression was derived. But not everyone who is under stress automatically falls ill with depression. Here, genetic predispositions and learned processing mechanisms seem to be noticeable. Often, the onset of the illness is related to a stressful life situation or a drastic life event such as the death of a close relative, the birth of a child or retirement. Here the depression seems to result from a lack of adaptation to the new situation.
Symptoms of depression
Not every depression shows up in the same way. However, the symptoms often begin slowly and are not specific: While one person always feels tired, energetic and depressed, another person suffers from physical complaints such as loss of appetite or abdominal pain. Especially at the beginning of the disease, the symptoms are often overlooked or assigned to completely different reasons, which can complicate the diagnosis and delay.
The three main symptoms of depression are:
- depressed, sad mood that persists most of the day, almost every day
- Loss of interests and activities that have always been enjoyable
- Low driving power and a rapid fatigue, which can not be justified by the activities performed
Complaints vary greatly from person to person
As in the beginning, the course of the disease is very individual. While some people are so depressed that they can barely manage the budget, others are tormented by failure fears and hopelessness, but manage to pursue a regular everyday life.
The three main symptoms of depression may be accompanied by further complaints. On the psychological level, these are above all:
- lower concentration and attention
- decreased self-confidence and self-esteem
- negative thoughts about the future or future fears
- Feelings of guilt and worthlessness
- Thoughts of (or attempted) self-harm or suicidal acts
In addition, symptoms can also occur on a physical level. Which includes:
- Loss of appetite, which has led to a weight loss of more than 5% of body weight in the last 30 days
- Loss of libido
- Sleep disorders, which are typically associated with early morning awakening
- Morgentief (drive inhibition occurs especially in the morning, the "get in the gears" is very difficult)
- Tightness in the chest, which may be accompanied by cardiac arrhythmias or palpitations
- Headache and abdominal pain that can not be assigned to any other cause
- Dizziness and circulatory problems
Sometimes only physical complaints
In older people, but also in children, depression can only be manifested through physical complaints. For the complaints, however, no treatable physical causes can be found, which means that those affected unsuccessfully visit many doctors (or be sent from doctor to doctor). In this case, one speaks of a sedated depression. In some cases, depression also affects the drive. Many sufferers express a reduced facial expression and physical mobility (inhibited depression). Others, on the other hand, feel inwardly driven, always on the move, and seldom come to rest (agitated depression). In very severe cases, a "feeling of numbness" can occur, which is perceived as very distressing. At the same time, the mood is so reduced or reduced to a certain level that even greater success or heavy impact can no longer bring about a change in sentiment in one direction or the other. Affected people feel like they are trapped and act impassively on their environment.
Diagnosis of depression
Although a quick diagnosis and treatment of depression is very important, there is often a lot of time between the first symptoms and the start of treatment.This is mainly due to the fact that those affected and the medical profession often do not properly perceive or misclassify the initially very unspecific complaints. Furthermore, it is often difficult for patients to admit the complaints and to talk about it because depression is still strongly stigmatized.
To diagnose a detailed conversation with a doctor or psychologist is inevitable. Standardized questionnaires or anamnesis guides can be used to find out if depression is present and how severe it is.
The diagnostic criteria are considered met when two to three of the main symptoms listed above (depressed, sad mood, loss of interest / joylessness and lack of drive) exist over a period of at least two weeks.
Depending on whether and what other symptoms occur, the depression is divided into three severity levels: easy, moderate or severe. This classification is important in order to select the right treatment methods.
Bipolar or unipolar
In addition to the severity, the type of depression is always determined in order to obtain a better picture of the disease and, if necessary, to be able to make a statement about the prognosis. A single episode of depression is called a depressive episode. Repeat these phases, it is a recurrent (recurrent) depressive disorder. If phases of depression alternate with periods of high mood (mania), bipolar disorder is referred to. This is usually harder to recognize and treat than the unipolar depression, ie a depression without these changes.
Mild depressive moods that do not meet the criteria of true depression but last two years or more are called dysthymia. A similar mood impairment is also present in winter depression (seasonal affective disorder), which occurs mainly in autumn and winter and is caused by lack of daylight.
Treatment of depression
The therapy of depression is usually based on the two pillars of drug treatment and psychotherapy. In many cases, both approaches are used in combination, always including the severity and type of depression as well as the desire of the patient in the treatment decision.
Waiting also possible
For mild depression, two therapy concepts can be considered:
- In consultation between the patient and the doctor can first be waited. This concept of "wait-and-see" is often used in general practice and is based on the idea that many ailments reappear on their own. For mild depression, this concept should be considered in consultation between doctor and sufferer. Instead of medically prescribed treatment, more general measures such as sport and social exchange should be used.
- If the symptoms do not disappear or if you wish to be treated directly as a person affected, psychotherapy is usually started. In the case of mild depression, therefore, first of all a medication is dispensed with.
Approach to stronger depression
Moderate depression can be treated either medically or psychotherapeutically.
In severe depression, both drugs and a psychotherapeutic intervention should be used.
These two therapeutic cornerstones we will introduce in more detail below.
There are many different forms of psychotherapy. In the case of depression, behavioral and depth-psychological treatment approaches have proven to be particularly effective. Psychotherapy can be used as the sole form of treatment for mild depression and is combined with drug treatment for moderate to severe depression.
Cognitive behavioral therapy has proven particularly useful for the treatment of depression. It aims to identify and transform depressive patterns of behavior and thought patterns into positive ones in order to escape the mental downward spiral. Thus, the focus of this treatment approach is not solely behavioral change, but also to recognize automated thoughts, to be aware of their impact on the behavior and the emotional level and then to control. The therapist helps to uncover thinking mistakes and generate positive thoughts. For example, a generalized negative thinking pattern such as "I always blame everything" is gradually replaced by one that is no longer characterized by negative expectations: "Last time it was my fault, this time I have nothing to answer for".
Cognitive Behavioral Therapy relatively quickly achieves very good treatment outcomes in depression as it teaches strategies that can be used everyday in everyday life.
The depth psychology assumes that unconscious conflicts from early childhood and adolescence contributed to the development of the current diseases.Thus, these internal conflicts must be worked over to bring about a cure. This examination of the unconscious past often lasts for several years, sometimes with several appointments per week, which is why a deep psychology-based psychoanalysis is not used as standard in depression. On the other hand, interpersonal psychotherapy (IP) has become established as a depth psychology procedure for the treatment of depression. The victim is helped to solve interpersonal problems caused by depression in the interpersonal sphere. Another important aspect is dealing with the ill effects of stressful situations and how they can be managed with existing resources. The advantage of interpersonal therapy is that it only lasts 12 to 20 sessions and has a relatively early onset of effect. Accompanying measures, which can positively supplement a psychotherapy, are the establishment or the preservation of an active, regular daily structure as well as a stable social network.
A drug treatment of depression with antidepressants must be weighed in individual cases, but is usually only from a moderate disease form used. Antidepressants work in very different ways and depending on the person different fast and strong. Sometimes certain remedies do not work for certain people. For that reason, there is not one drug of choice that can bring a guaranteed benefit to any depression. Rather, it is about finding a preparation that achieves individual good efficacy and causes as few side effects as possible. The therapy is started with the drug from which the practitioner hopes the best effect. If the desired effect does not occur even after the dose has been increased or if the side effects are too severe, the preparation is changed.
Pros and cons: what you need to know
It is important for the user to know that the effects of the antidepressant will not be fully effective until after three to six weeks, but that side effects such as tiredness, weight gain and indigestion may be used earlier. Only after this time can therefore be taken stock and decided whether the product should be retained or replaced. Contrary to many prejudices, antidepressants are not addictive and usually do not change the personality. They have side effects but more often, especially in the first weeks of treatment. And even putting down the tablets can cause problems, especially if the dose is reduced too quickly. According to the S3 guidelines of the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN), antidepressants should be taken in a first depressive episode over a period of 4-9 months after the disappearance of the symptoms. For two or more depressive episodes, therapy should be for at least two years. After this phase, the preparations can be gradually reduced in consultation with the doctor and finally omitted altogether. In many cases, the weaning then succeeds without it comes to a new episode of illness.
Tricyclic & Tetracyclic Antidepressants
Tricyclic and tetracyclic antidepressants are among the oldest drug classes for the treatment of depression. They influence the concentration of many different neurotransmitters in the brain. Thus, the activity of norepinephrine, serotonin and Dopamine is increased, which increases both drive and mood. The name of the drug group, however, refers to the chemical structure, not to the number of affected neurotransmitters.
However, this versatile effect is also a problem: it leads to a wide range of side effects, which is a major disadvantage of this group of drugs.
Active substances of the group of tricyclics are:
- Amitriptyline (e.g., Saroten®)
- Clomipramine (e.g., Anafranil®)
- Doxepin (e.g., Aponal®)
- Imipramine (e.g., Tofranil®)
- Nortriptyline (e.g., Nortrilen®)
- Trimipramine (e.g., Herponal®, Stanyl®)
Active substances of the tetracycline group are:
- Maprotiline (e.g., Ludiomil®)
- Mianserin (e.g., Tolvin®)
- Mirtazapine (e.g., Remergil®)
SSRI & SSNRI
Selective serotonin reuptake inhibitors (SSRIs) are the most well-known antidepressants. Which medications are all included is listed below. In contrast to the tricyclic and tetracyclic antidepressants, SSRIs only act on the messenger substance serotonin. They inhibit the re-uptake of serotonin into brain cells, thereby increasing the amount of this mood-enhancing messenger that is freely available.
The selective serotonin norepinephrine reuptake inhibitors (Selective Serotonin Norepinephrine Reuptake Inhibitor = SSNRI) inhibit accordingly the uptake of serotonin and norepinephrine. Through this mechanism, the representatives of these two groups act relatively targeted mood-enhancing and also against fears, but more often also lead to cardiovascular complaints, headaches and gastrointestinal problems.
Active substances of the group of SSRIs are:
- Citalopram (e.g., Cipramil®, Seropram®)
- Escitalopram (e.g., Cipralex®)
- Fluoxetine (e.g., Fluxet®, Prozac®)
- Fluvoxamine (e.g., Fevarin®)
- Paroxetine (e.g., paroxet®, Seroxate®)
- Sertraline (e.g., Zoloft®)
Active substances of the group of SSNRI are:
- Duloxetine (e.g., Cymbalta®)
- Milnacipran (e.g., Milnaneurax®)
- Venlafaxine (e.g., Trevilor®)
Other medications include moclobemide (e.g., Aurorix®, Rimoc®) and tranylcypromine (e.g., Jatrosom®), which belong to the group of MAO inhibitors, but are rarely used today. As the name implies, these drugs inhibit the enzyme monoamine oxidase (MAO), which is normally responsible for the breakdown of norepinephrine and serotonin. If this degradation does not take place, the freely available concentrations of the transmitters in the brain increase. One drawback is that other transmitters in other parts of the body will not break down, so many side effects can result. Furthermore, when taking tranylcypromine a strict diet must be followed, in which to do without cheese, dark chocolate and red wine.
If no antidepressant has shown sufficient efficacy and other treatment approaches have not been promising, lithium can be used. Lithium salts do not belong to the class of antidepressants, but can be used for augmentation. This means that they can increase the effect of conventional antidepressants with concomitant use. Since lithium (e.g., Hypnorex®) but only in a very narrow range and can cause serious side effects in case of deviations from this framework, it should only be prescribed by an experienced doctor. In addition, then regular checks are necessary.
Do not prescribe premature medication
An important aspect, which is often underestimated, is the discontinuation problem with the drugs. And in two ways:
- 1. You should not stop taking antidepressants prematurely.
- 2. And you should proceed step by step when stopping.
First to point 2: A sudden stop of drug therapy can lead to severe mental and physical side effects. These are not withdrawal symptoms in the true sense, because antidepressants do not make dependent. However, it is still very unpleasant symptoms that can be avoided if you make the dosage carefully and gradually in consultation with the doctor.
Then to point 1: About six weeks after starting treatment with antidepressants, it usually comes into effect. After another six to eight weeks many sufferers feel so good again through the tablets and the accompanying therapy that the medication seems superfluous. A fallacy! In order to maintain the hormonal balance in the brain, the drugs usually need to be taken longer, even if the acute depressive mood is overcome. Early withdrawal can provoke a relapse. In case of doubt, you should definitely talk to your doctor in detail.
Further treatment measures
Depending on the wishes of the patient or the experiences and preferences of the doctor, there are a number of other treatment methods that can be used to support depression:
The light therapy is mainly used during winter depression. Here mab receives a "light shower" of artificial light directly after waking up. The effect is believed to be due to decreased melatonin secretion in the brain. Melatonin is thought to promote depression. As a result, the symptoms diminish with reduced production and release of the hormone.
sleep deprivation therapy
In this form of therapy, the person is temporarily deprived of sleep completely or partially (usually then in the second half of the night). However, the short-term antidepressant effect that begins after a therapy cycle usually does not last long. The depressive symptoms usually return when a normal night is slept again.
Electroconvulsive therapy is used as a last resort in severe depression when neither medication nor other treatments have helped to ameliorate the condition. Under anesthesia, muscle relaxation and ventilation, the brain is electrically stimulated directly, causing a seizure. For success to be achieved, the procedure must be repeated several times. For this every time a hospital stay is necessary. Why this method can be effective in depression is still unclear. In studies, however, good results could be achieved without producing lasting damage.
In support of depression should be regularly driven sports. Exercise promotes the release of adrenaline and dopamine and can thus increase the well-being.In addition, it is important to pursue a well-structured everyday life and be socially involved. General measures alone are often not enough to cure the depression, but can support the recovery process and are important to prevent further depressive episodes.
Prognosis & relapse prevention
The prognosis of depression depends on many factors and can only be predicted with difficulty in individual cases. Critical to the course of the disease are the number of depressive episodes so far, the duration of each episode and the severity of the disease. But the timing of the start of treatment and the response to medication and psychotherapy are crucial for a favorable prognosis.
Numerous studies have shown that in two out of three cases, depressive episodes are self-limiting and even after six to eight months without treatment, they are all by themselves. However, therapy offers two advantages: On the one hand, the active phase of the illness can be shortened and, on the other hand, targeted treatment reduces the risk of having to go through another depressive episode. However, in one third of those affected, the symptoms with or without therapy improve only partially, or even 15% lead to chronic depression. Nevertheless, the chances of a depression are good:
- Left untreated, two thirds of depressive episodes disappear on their own;
- About half of these patients suffer a second depressive episode;
- the other half has completely overcome the disease.
Unfortunately, it can not be predicted who belongs to which group. However, it is a fact that concomitant diseases, such as obsessive-compulsive disorder or anxiety, as well as the use of alcohol and drugs have a negative effect on the course of the disease and increase the risk of relapsing.
Do not perceive relapse as a defeat
After completing the medically prescribed treatment, many sufferers find themselves in a certain inactivity again. The therapy is a big step, but what comes next? To avoid this unemployment, hobbies and passions such as sports or art should be resumed or restarted during therapy. Heavier phases can then be mastered better on their own and with their own resources.
However, relapses can be part of depression and should not be considered a personal weakness or defeat. It is much more important to recognize the warning signs and to control them as quickly as possible. This is best achieved by an open approach to the disease.
Everyday life with depression & self-help
Living with depression is difficult, especially at the beginning. It is important to realize that depression is a common disease that nobody can care about. Depression is not the expression of failure or personal weakness.
The open management of the disease helps to reduce stigmata. Many sufferers are afraid of meeting with incomprehension and rejection when they talk about their illness. As a rule, the opposite is the case.
Also take advantage of other treatment offers
Parallel to psychotherapy further supportive therapy options can be used. After completion of the medical treatment, they can be used as a means of self-help in acute situations. The range is very broad and ranges from movement and art therapy to group companies. The greatest positive effect seems to be sport, which is both preventive to a new episode of disease and therapeutically effective in acute illness. Self-help groups are another way to cope with everyday life. Especially after the end of the therapy, conversations with other people can help to feel understood and not left alone with their worries and fears. The connection to a suitable group is usually very easy in the age of the Internet. There are also opportunities online to exchange experiences.
Authors: Lisa Wunsch & Dr. med. med. Jörg Zorn
- German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN), S3 Guideline / National Care Guideline Unipolar Depression (pdf)
- Michael Rentrop, Rupert Müller, Hans Willner: Clinic Guide Psychiatry Psychotherapy. Elsevier, Urban & Fischer Verlag, 2016
- Siegfried Kasper, Hans-Jügern Möller: Autumn / Winter Depression and Light Therapy. Springer-Verlag, 2011
The main questions and answers: a comment
How can I cure my depression? The most important medical questions at a glance. On this Navigator-Medizin portal, we answer relevant questions on the subject of "depression" - from the causes to recognition and treatment, to daily routine and to prevention.
A brutal disease
Three typical signs of depression are depressed mood, lack of interest and prolonged fatigue. This may sound relatively harmless to the outsider, for the person affected by a severe depression, it is felt hell. Because the depression affects the mind and not the mind. It has nothing to do with "insanity" in the sense of insanity.On the contrary, the depressive person can observe himself as he is in the end unable to act anymore. The conscious experience of one's own weakness is one of the particular brutalities of this disease, which is not palpable for healthy people without experience of depression. The often expressed by relatives appeal "pull yourself together" is literally in the void and worsens by reinforcing the pathological feelings of guilt of the depressive whose situation at most.
Often not easy to recognize
However, depression often develops creepingly and is not recognized for a long time either by the affected person or by his environment. Many family doctors are obviously overstrained with the diagnosis. In any case, it is estimated that only half of the depressed individuals who ever seek medical treatment are recognized as such. To make matters worse, that a depression has many different faces and can also hide behind a mask. In this case, experts speak of a latent depression, such as manifested by physical symptoms, e.g. but also behind an addictive behavior, especially in men, may be due to a depression.
Causes complex - and often nebulous
There are various forms of depression and also different causes for their emergence. The development process is not yet clarified. It is suspected a hereditary predisposition. The possible triggering factors are numerous and work from inside or outside. Above all, they involve severe physical, mental or social burdens that overwhelm personal resilience. The external influences include lack of light, which can lead to the known winter depression.
Biggest danger: suicide
Depression is a very serious, potentially fatal condition affecting the whole human being. It is much more than a temporary mood low or a feeling fluctuation. In everyday language, the term "depressive" is often used quickly and lightly. But almost every seventh person, who is actually depressed, eventually kills himself. Suicide is thus the greatest danger of this disease, which causes not only serious human but also social and economic damage. Depression is something other than the now common burnout syndrome, which is less a diagnosis than a risk condition.
Depression is common - and curable
Depression is very common. They obviously belong to human life. It is believed that about every tenth to seventh person at some point in the course of his life suffering from the severe form of depression (major depression). If you take all the light forms, should be affected at any time over 10% of the population. Even if one should always be cautious about statistical statements, especially in the healthcare sector, it is clear that depression is a very relevant and apparently even increasing disease in our society. This is also confirmed by the high inflow to psychiatric and psychotherapeutic clinics and practices as well as the great interest of the pharmaceutical industry in the research and especially marketing of antidepressants. The good news, after all, is that the chances of success in the treatment of a depressive episode are good. And even better: depression is basically curable. Sometimes, medical care is enough to make the self-healing mechanisms work effectively. Often, the affected person has to lay hands on his thinking, feeling and behavior, in order to become and stay healthy in the long term.
Antidepressants, psychotherapy and self-healing
In the acute phase of severe depression, there is hardly any approach to the affected person. Above all, the time in a sheltered room helps here, as apart from a very understanding and well-guarded home, it can only offer a psychiatric clinic.
Medications can be helpful in reducing suffering and facilitating entry into psychotherapeutic treatment. There are different types of antidepressants that affect the brain metabolism and the messenger substances acting there. The palette is wide and reaches u.a. from the older tricyclics to the more recent selective reuptake inhibitors of serotonin and / or norepinephrine (SSRI, SNRI, NARI). A classic in the treatment and especially prevention of (further) depressive episodes is lithium. With herbal remedies, severe levels of depression can not be dealt with, but in milder cases St. John's wort has proved its worth. All antidepressants have advantages and disadvantages, some of them can increase the tendency to depression and even the suicidal in the worst case.
As soon as you feel better: Become active for your health!
The blanket rejection of these psychotherapeutic drugs, however, is just as unjustified as their sweeping application, regardless of the individual circumstances and needs of the patient. Incidentally, this also applies to other treatment methods such. Group therapy procedures. They have advantages not only for the practitioner, but also for the treated, but not all.Understandably, it is particularly difficult for depressive patients to introduce themselves into the treatment process. This is even more important after the acute episode: Get active and enjoy the regained freedom to act responsibly. Do not continue where you may have slipped into depression. Instead, you use the experience of depression as an opportunity to realign the way you deal with yourself and your life, your purpose and your framework. Then you can live happier after the depression than before.
Author: Dr. Hubertus Glaser