Major Depression: Major Misconceptions
Many Fail to Recognize the Signs

By Carla Cantor
WebMD Health

You don't have to feel sad or blue to be depressed. Depression can descend upon you in disguise, masked as a stomachache, back pain, or exhaustion. These and other physical symptoms can camouflage the emotional side of this serious psychiatric illness.

The vague physical complaints and unexplained symptoms that often accompany depression can be confusing not only to you but also to your doctor. Studies show that primary care physicians fail to recognize depression in the majority of cases and rarely check for the disorder. The result: Less than one-third of those who suffer major depression ever receive treatment.

Many people suffering from depression believe they are sick and end up in their doctor's office only to be told that there is nothing wrong. These people are in emotional pain, but they feel more comfortable talking about their physical distress, says Paul A. Kettl, MD, acting chairman of the department of psychiatry at the Pennsylvania State University College of Medicine. That's because the stigma attached to depression is still enormous, Kettl says, despite the fact that 10 million Americans will experience depression in any given year. Of all people who seek medical attention, 5-9% suffer from depression.

Depression is costly. One study estimated the national tab for depression in the U.S. at a whopping $43.7 billion a year, mainly in treatment and lost productivity. This doesn't include the unnecessary medical costs incurred by misdiagnosed patients. Major depression, however, costs more than money.

Consider:

• Men who suffer depression have a higher risk of heart disease.

• Depressed nursing home residents are twice as likely to die as those who are not depressed.

• Depression is the cause of at least half of all suicides.

Undiagnosed, depression can take months or years to resolve. Without treatment, it may end in suicide. So it is vital to be alert to warning signs in yourself and your loved ones and to seek prompt treatment if symptoms begin or return.

 Recognizing the Symptoms and Signs

Typically, major depression doesn't develop overnight. It grows gradually over days or weeks. Though its hallmark is a blue mood and a lack of interest in activities, the clinical picture is not the same for everyone, and classic symptoms may not appear until later. The physical signs of depression can range from insomnia and weight change to memory loss and sexual dysfunction. Fatigue, pain, weakness, headache, dizziness, constipation, and stomachache are also common.

Getting help begins with recognizing that depression needs -- and deserves -- to be treated. The feeling that you should deal with these depressive feelings may be strong and get in the way of seeking help. That's a mistake. A stoical attitude can drive major depression underground -- into bodily aches and pains or destructive behaviors such as alcohol or drug abuse.

If you suspect depression, you should see your doctor immediately. Describe your symptoms and how long they have lasted. If possible, bring a family member or close friend with you. Your doctor may want to order some tests and conduct a full physical exam to rule out other diseases.

Treatment Options

Once depression is diagnosed, your doctor may refer you to a psychiatrist or offer to treat you himself. Some primary care physicians are skilled in managing depression. Whether you choose a family physician or a psychiatrist, the next step is for you and your doctor to talk over your options.

The cornerstone treatment of depression is medication, which in many cases is combined with psychotherapy. There are dozens of effective antidepressants on the market. Most commonly used antidepressants seem to affect the brain's chemical messengers -- neurotransmitters -- though scientists don't understand exactly how or why these drugs work.

Many doctors use the selective serotonin reuptake inhibitors (SSRIs) as a first-line approach to major depression. The best known of this class, Prozac, has been used as an antidepressant in the U.S. for more than 10 years. SSRIs generally do not have serious side effects, although some people experience nausea or headaches at the beginning of treatment and a decrease in sexual function or desire later on. Once antidepressants have begun to take effect, psychotherapy may assist in identifying the underlying causes of the depression to help prevent future episodes.

Don't get frustrated if you don't see results right away. As with most antidepressants, SSRIs may need to be taken for 6 to 8 weeks before patients feel the full effect. About one-third of sufferers do not respond to any one drug, and experimentation may be necessary. There are several other groups of antidepressant medications, and you should discuss these with your doctor. They include the tricyclics, the monoamine oxidase inhibitors (MAIOs), and the new dual-acting antidepressants, which act on two neurotransmitters (the SSRIs act on only one, serotonin).

Finally, for depression that doesn't respond to medications, electroconvulsive (shock) therapy, called ECT, is an alternative. This may be the treatment of choice when there is danger of suicide. Shock therapy, which has changed dramatically since the 1950s, is considered safe and effective. Although it does cause some short-term memory loss, shock therapy relieves depression 75-85% of the time.

For some people, depressive episodes will occur throughout life. Therefore, establishing a long-term relationship with a doctor in whom you have confidence is crucial. The good news is that depression is the most treatable of all psychiatric illnesses. With proper treatment, 80-90% of those suffering will see dramatic improvement -- often full recovery -- within weeks or months.

The Warning Signs

Doctors diagnose major depression when at least five of the following signs appear nearly every day for at least 2 weeks:

• Depressed mood or persistent irritability.

• Loss of interest in pleasure or activities.

• Significant weight loss or gain, or a change in appetite.

• Insomnia or excessive sleeping.

• Change in activity (increased or decreased).

• Fatigue or loss of energy.

• Decreased ability to think, concentrate, or make decisions.

• Feelings of worthlessness or excessive or inappropriate guilt.

• Recurrent thoughts of suicide, or attempted suicide.

Risk Factors for Depression

The causes of major depression aren't fully understood. Sometimes major depression can result from a traumatic event, such as a death of a loved one. Or it may occur in the wake of hormonal changes after childbirth or during menopause. Physical diseases, like abnormal thyroid function, can trigger depression; so can certain medications. In most cases, however, depression appears to arise for no perceptible reason. Here are some factors that may increase one's susceptibility:

Being a woman: Women are twice as likely to experience depression as men, a statistic that holds true across all cultures.

Having relatives with depression: A family history of depression increases the risk of experiencing a major depressive episode.

Being between 20 and 40 years old: The peak age for depression is 20 to 40 years of age.

Experiencing grief: Grief increases the risk of depression; for example, in one study, 2 months after the death of a loved one, a third of all mourners met the criteria for major depression.

Suffering from a brain disorder: Disorders affecting the brain are associated with depression; of patients who survive a stroke, 25% experience major depression within 2 years.

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