Depression can affect people of any age, including children. Studies have shown that 2% of teenagers in the UK, are affected by depression.

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1 Page 1 of 11 Introduction is a serious illness. Health professionals use the terms 'depression', 'depressive illness' or 'clinical depression' to refer to something very different from the common experience of feeling miserable, or fed up, for a short period of time. The facts If you are depressed, you may have feelings of extreme sadness that can last for a long time. These feelings are severe enough to interfere with your daily life, and usually last for weeks, or months, rather than days. is quite a common condition, and about 15% of people will have a bout of severe depression at some point in their lives. However, the exact number of people with depression is hard to estimate because many people do not get help, or are not formally diagnosed with the condition. Most of the 5,000 suicides committed each year in the UK are linked to depression. On average, 15% of people with recurrent depression (repeated attacks) have an increased risk of suicide. Women are twice as likely to suffer from depression as men, although men are far more likely to commit suicide. This may be because men are more reluctant to seek help for depression. can affect people of any age, including children. Studies have shown that 2% of teenagers in the UK, are affected by depression. People with a family history of depression are more likely to experience depression themselves. affects people in many different ways and can cause a wide variety of physical, psychological (mental) and social symptoms. What is depression? Doctors describe depression in the following three ways: by how serious it is - if it is mild, it is likely to have some impact on your daily life, if it is moderate, it is likely to have significant impact on your daily life and, if it is severe, daily activities may be almost impossible. by physical symptoms - if you have depression, you will probably have one or two (or maybe more) physical (somatic) symptoms, such as tiredness or a loss of appetite. by psychotic symptoms - if you have depression, you may also have psychotic symptoms, such as hallucinations, or delusions. However, these symptoms do not affect everyone with depression. A few people still think that depression is 'not a real illness', and that it is some sort of 'weakness', or admission of failure. This is simply not true. is a real illness with real effects, and it is

2 Page 2 of 11 certainly not a sign of failure. In fact, famous leaders, such as Winston Churchill, Abraham Lincoln and Mahatma Gandhi, all experienced bouts of depression. Symptoms If you are depressed, you often lose interest in the things that you used to enjoy. can interfere with your work, your social life, and your family life. In addition, there are many other symptoms, which can be physical, psychological, and social. Psychological symptoms Psychological symptoms of depression include: continuous low mood, or sadness, feelings of hopelessness and helplessness, low self-esteem, tearfulness, feelings of guilt, feeling irritable and intolerant towards others, lack of motivation, and little interest in things in general, lack of enjoyment, difficulty making decisions, suicidal thoughts, or thoughts of harming someone else, feeling anxious or worried, and a reduced sex drive. Physical symptoms Physical symptoms of depression include: slowed movement and speech, change in appetite and weight (your weight will usually decrease, but sometimes it may increase), digestive complaints, such as indigestion, constipation or diarrhoea, unexplained aches and pains, lack of energy and a lack of interest in sex, and changes to the menstrual cycle (in women). Social symptoms Social symptoms of depression include: not performing well at work, taking part in fewer social activities, and avoiding contact with friends, reduced hobbies and interests, and difficulties in home and with family life. Grief and depression Even though grief and depression share many of the same characteristics, there are important differences between them. Grief is an entirely natural response to a loss, while depression is an illness. However, sometimes, it can be hard to distinguish between feelings of grief and depression.

3 Page 3 of 11 People who are grieving find that feelings of loss and sadness come in waves, but they are still able to enjoy things, and are able to look forward to the future. However, those who are depressed have a constant feeling of sadness, they do not enjoy anything and have little sense of a positive future. Causes There are many different factors that can trigger depression. For some people, upsetting, or stressful life events, such as bereavement, divorce, illness, redundancy, and job or money worries, can be the cause. This is often known as 'reactive depression', where depression is a reaction to the event. It is also sometimes referred to as exogenous depression ('exogenous' is a Latin word that means originating outside the body). In other cases, depression does not have an obvious cause. This is called endogenous depression (originating within the body). As depression can have many causes, it is sometimes divided into three broad groups - psychological, physical and social. Psychological - is where a stressful, or upsetting, life event causes a persistent low mood, low self-esteem and feelings of hopelessness about the future. Physical or chemical - depression is caused by changes in levels of chemicals in the brain. For example, your mood can change as hormone levels go up and down. This is often seen in women as it is associated with the menstrual cycle, pregnancy, miscarriage, childbirth, and the menopause. Social - doing fewer activities, or having fewer interests, can cause depression, or may happen because of depression. Family history If you have a family history of depression, you are more likely to get depression yourself. Studies have shown that different versions of a gene (known as 5-HTT) can be inherited which can have an affect on a natural, mood changing chemical in your brain, called serotonin. About 20% of people have got what geneticists (gene specialists) call the 'short' version of the 5-HTT gene, and it is these people who are more likely to develop depression after a stressful life event. Research as shown that there is a link between depression and the imbalance of chemicals in the brain called neurotransmitters. People who are depressed have a lower level of certain types of neurotransmitters, such as serotonin, norepinephrine and dopamine, than people who are not. It is still not fully understood whether this imbalance is a result of depression, or a cause of it. Children inherit the 5-HTT gene from their parents, so having a history of depression in the family can increase your risk of developing it. In other words, you have a 'genetic predisposition' for depression. On the other hand, many people who have a family history of depression never develop the condition. Also, people with no family history of depression can become depressed. There is rarely one single cause of depression - usually, different causes combine to trigger the condition. For example, you may feel low after an illness and then experience a stressful life event, such as bereavement, which leads to depression. People often talk about a 'downward spiral' of events that lead to depression. For example, if a

4 Page 4 of 11 person's relationship with their partner breaks down, they are likely to feel low, they may stop seeing friends and family, and start drinking more - all of which can make them feel even worse, and trigger depression.. Other causes of depression Other frequent causes of depression include: drinking excess alcohol - men should not drink more than 3-4 units of alcohol a day and women no more than 2-3 units a day. A unit of alcohol is roughly the same as half a pint of normal strength lager. Use the interactive drink calculator to find out how many units of alcohol you consume in a day, using recreational drugs - such as cannabis and cocaine, and taking some types of prescription medication - for example, propranolol can occasionally cause depression. Diagnosis If you think you have depression, you should visit your GP. Your GP may give you a physical examination and do some blood or urine tests to rule out other conditions that have similar symptoms such as lupus, under-active thyroid, or fibromyalgia. There are no clinical tests for depression so detailed interviews and questionnaires are usually used to make a diagnosis. There are many different questionnaires used to measure depression. However two classifications of mental illness are most widely used. Diagnostic and Statistical Manual of Mental Disorders This system was developed by the American Psychiatric Association. It is a classification system based on all the known recorded symptoms associated with a particular mental condition. Your GP will ask you if you have certain symptoms, and depending on your answers, will be able to use the system to identify what the condition is. International Classification of Diseases This is a similar system of classifications, again based on the known symptoms associated with particular diseases. Developed by the World Health Organisation, it is a much wider system, covering all diseases, not just mental conditions. Again your GP will ask you about your symptoms in order to classify your condition. Using one of these two guidelines, it is usually possible for your GP to diagnose depression, decide which type of depression you are experiencing, and to rule out other mental conditions. Any discussion that you have with your GP about your depression will be treated in the strictest of confidence. Your GP will only ever break this rule if there is a significant risk of harm to either yourself, or to others, and if informing a family member, or carer, would reduce that risk. Treatment

5 Page 5 of 11 Treatment for depression usually involves a combination of using medication and psychological therapies. Mild depression If you are diagnosed with mild depression, but your GP thinks you will improve, you should have another assessment in two weeks time to monitor your progress. This is known as 'watchful waiting'. If you have mild depression, antidepressants are not usually recommended as a first treatment. Exercise seems to help some people with depression. While your progress is being monitored, your GP may refer you to an exercise scheme with a qualified fitness trainer. Talking through your feelings may also be helpful for mild depression. You may wish to talk to a friend or relative, or your GP may suggest a local self-help group. Your GP may also recommend self-help reading materials and computerised cognitive behaviour therapy (CBT) (see below for further details). If your depression is mild, but you have a history of depression, your GP may suggest that you start a course of antidepressants (see below for further details). Chronic mild depression (present for two years or more) is called dysthymia. It is more likely in people over 55 years of age and can be difficult to treat. As with mild depression, if you are diagnosed with dysthymia, your GP may suggest that you start a course of antidepressants. Moderate depression If you have mild depression which is not improving, or you have moderate depression, your GP may recommend a 'talking treatment', or prescribe an antidepressant (see below for further details). Severe depression If you have severe depression, your GP may recommend that you take an antidepressant, together with talking therapy. In cases of severe depression, a combination of an antidepressant and cognitive behaviour therapy (CBT), usually works better than having just one of these treatments. If you have severe depression, or your depression does not respond to treatment from your GP, you may be referred to a mental health team. These teams are usually made up of psychologists, psychiatrists, specialist nurses, and occupational therapists. They often provide intensive specialist talking treatments, such as cognitive therapy or psychotherapy. Talking treatments Cognitive behavioural therapy (CBT) Cognitive behavioural therapy (CBT), problem-solving therapy, and counselling, are examples of talking treatments. You normally have a fixed number of sessions - usually 6-8 sessions over weeks. Some GP practices have counsellors specifically to help patients with depression. Cognitive behavioural therapy (CBT) is based on the principle that the way we feel is partly dependent on the way we think about things. It teaches you to behave in ways that challenge negative thoughts - for example, being active to challenge feelings of hopelessness. Interpersonal therapy (IPT)

6 Page 6 of 11 Interpersonal therapy (IPT) focuses on your relationships with other people and on problems, such as difficulties with communication, or coping with bereavement. There is some evidence that IPT can be as effective as medication or CBT, but more research is needed. Counselling Counselling is a form of therapy that helps you to think about the problems you are experiencing in your life, in order to find new ways of dealing with them. Counsellors support you in finding solutions to problems, but do not tell you what to do. Research has shown that antidepressants and talking therapies are equally effective in treating mild, or moderate, depression, but having the two types of treatment together does not seem to offer any extra benefits. Your preference and the availability of talking therapies will be taken into account when deciding which treatment is most appropriate for you. Antidepressants Antidepressants take 2-4 weeks to take effect. If the first antidepressant you try is not effective, or causes side effects, it may be necessary to change the dose. Sometimes, a different type of antidepressant will be recommended. Your GP, or specialist nurse, should see you every 1-2 weeks when you start taking antidepressants. You should continue taking the antidepressants for at least four weeks (six weeks if you are elderly) to see how well they are working. If your antidepressants are working, treatment should be continued at the same dose for at least four to six months (12 months if you are elderly) after your symptoms have eased. If you have a history of depression, you should continue to receive antidepressants for up to five years, or longer. Antidepressants are not addictive but withdrawal symptoms are quite common if you stop taking them suddenly, or you miss a dose. SSRIs If your GP thinks you would benefit from taking an antidepressant, you will usually be prescribed an SSRI (selective serotonin reuptake inhibitor).these are as effective as the older TCAs (tricyclic antidepressants) and have fewer side effects. Fluoxetine, citalopram and sertraline are all examples of SSRIs. You will normally only be prescribed other sorts of anti-depressants, if the SSRI's do not prove to be effective. SSRIs increase the level of a natural chemical in your brain called serotonin which helps to lift your mood. You may have some side effects when you start taking SSRIs, such as nausea, headache, sleep problems and anxiety. However, these tend to improve over time. Some SSRIs should not be prescribed for children under the age of 18 years. Research shows that the risk of self-harm and suicidal behaviour may increase if they are used to treat depression in this age range. Fluoxetine is the only SSRI that may be prescribed for under-18s, but only when specialist advice has been given. Other antidepressants include: TCAs (tricyclic antidepressants), such as dothiepin, imipramine, and amitryptyline. These are used to treat moderate to severe depression. They work by raising the levels of the chemicals serotonin and noradrenaline in your brain which both help to lift your mood. You should not smoke cannabis if you are taking TCAs because it can cause your heart to beat

7 Page 7 of 11 rapidly. MAOIs (monoamine oxidase inhibitors), such as phenelzine sulphate, is sometimes used to treat 'atypical depression'. This is when you tend to eat and sleep more than usual. You should not smoke cannabis if you are taking MAOIs because it may affect the way these medicines work, and it is not clear what effect this may have on you. New antidepressants, such as venlafaxine, nefazodone, and mirtazapine, work in a slightly different way from SSRIs and tricyclics. These drugs are known as SSNI's (Serotoninnorepinephrine reuptake inhibitors). Like TCA's, these antidepressants work by changing the levels of serotonin and noradrenaline in your brain. Studies have shown that a SSNI like venlafaxine can be more effective than a SSRI, though it is not routinely prescribed as it can lead to a rise in blood pressure. St John's wort St John's wort is a herbal treatment that some people take for depression. Though there is some evidence that it may be of benefit in treating mild or moderate depression, its use is not recommended. This is because the quantity of its active ingredients vary among individual brands and batches, so it is uncertain what sort of effect it could have on you. Taking St John's wort with other medications, such as anticonvulsants, anticoagulants, antidepressants and the contraceptive pill, can also cause serious problems. You should not use St John's wort if you are pregnant or breastfeeding as there is not enough evidence that its use is safe in these situations. Electro convulsive therapy (ECT) Sometimes, other treatments, such as specialist medicines, or electro convulsive therapy (ECT), may be advised if you have severe depression. Electro convulsive therapy (ECT) works for severe depression, but it is only used when antidepressants and other treatments have not worked. If ECT is recommended for you, you will first be given an anaesthetic and medication to relax your muscles. You will then receive an electrical 'shock' to your brain through electrodes placed on your head. You may be given a series of ECT sessions. For most people, the treatment works well in relieving severe depression, but the effect may not be permanent. Some people may experience unpleasant side effects, including memory problems. Lithium If you have tried several different antidepressants and have experienced no improvement, your doctor may offer you a type of medication called lithium, in addition to your current treatment. There are two types of lithium - lithium carbonate and lithium citrate. Both are usually effective, but if you are taking one that is effective, it is best not to change. In order to work, you have to have a certain level of lithium in your blood. If this level becomes too high, the lithium can become toxic. Therefore you will need blood tests every three months to check your lithium levels. You should also avoid going on a low-salt diet because this can also cause the lithium to become toxic - consult your GP for advice about your diet. Before you start taking lithium, you should have an electrocardiograph (ECG) to check your heart Side effects

8 Page 8 of 11 SSRIs You may experience some side effects when you start taking SSRIs, including: nausea, headache, sleep problems, and anxiety. However, the above side effects tend to improve over time. TCAs Common side effects of TCAs (tricyclic antidepressants) include: dry mouth, constipation, sweating, problems passing urine, slight blurring of vision, and drowsiness. The side effects should ease after 7-10 days as your body gets used to the medication. However, if side effects continue, or become troublesome, you should tell your GP, as a switch to a different antidepressant may suit you better. MAOIs If you are taking MAOIs (monoamine oxidase inhibitors) you will have to avoid food that contains the chemical tyramine - which is normally found in foods that have been fermented or cured to increase their flavour - like cheese, pickled meat or fish. Your GP should give you a list of food and drink to avoid. You should not drink any alcohol, or fermented liquids, even if they are alcohol free. As MAOIs have the potential to interact with a wide range of medication, you should not take any other drug or medicine - even over-the-counter medication - without checking with your GP first. Common side effects of MAOIs include: blurred vision, dizziness, drowsiness, increased appetite, nausea, restlessness, shaking or trembling, and difficulty sleeping. In rare cases, MAOIs have the potential to cause a wide range of other side effects. You should check with your GP if you are concerned about any unusual symptoms that you have. There have been a number of cases where MAOIs have caused a dangerous rise in blood pressure. If you experience a stiff neck, severe headache, chest pains, vomiting or nausea, or a fast

9 Page 9 of 11 heartbeat, you should seek emergency help immediately by dialling 999 and asking for an ambulance. The restrictions involved in terms of diet, and the potential for side effects involved with taking MAOIs means that they are normally only prescribed when other treatments have not been effective. Other treatments Psychological therapies have few, if any side effects, but some other therapies do have some side effects. For example, ECT can cause short term headaches, memory problems, nausea and muscle aches. The complementary therapy St Johns wort may cause you to feel sick, and lead to dizziness and a dry mouth. Complications About half of the people who have a first episode of depression will have another episode within 10 years. The risk of further bouts of depression is higher than in someone who has never been depressed. Mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide. The warning signs of suicide Some of the warning signs that can signify people with depression are considering suicide are outlined below. Making final arrangements - such as giving away possessions, making a will or saying goodbye to friends. Talking about death or suicide - this may be a direct statement, such as 'I wish I was dead', but often depressed people will talk about the subject indirectly, using phrases like, 'I think dead people must be happier than us', or 'wouldn't it be nice to go to sleep and never wake up'. Self-harm - such as cutting their arms or legs, or burning themselves with cigarettes. A sudden lifting of mood - this sudden lift of mood could mean that a person has decided to commit suicide and feels better because of this decision. Helping a suicidal friend or relative If you see any of the above warning signs, you should: get professional help for the person, let them know that they are not alone and you care about them, and offer your support in finding other solutions to their problems. If you feel that there is an immediate danger, stay with the person, or have someone stay with them, and remove all available means to suicide. The most obvious means found in most people's houses is medication. Over-the-counter medication such as painkillers can be just as dangerous as prescription medication. Also remove sharp objects and poisonous household chemicals like bleach. Prevention

10 Page 10 of 11 To deal with depression, and help prevent repeated bouts of depression, you should: take your medicines regularly as directed, without skipping any days, discuss reducing or stopping medication with your GP, BEFORE you make any changes, gradually try to increase the activities that you enjoy, avoid smoking, illegal drugs and alcohol. These may appear to make you feel better in the short term, but can make you feel worse in the long term, use a problem solving approach to deal with stress and worry, try to identify negative thoughts and change them to positive thoughts, assess your symptoms regularly and consult your GP, or counsellor, if problems arise, increase the amount of exercise that you do. Exercise can trigger the release of the brain chemical serotonin, which boosts your mood. A simple programme of aerobic improves depression in some people, even when medication has not been effective. Studies show that a structured programme of aerobic exercise, such as like swimming, walking or jogging, taken under the supervision of an instructor, can be effective in treating depression. learn how to relax using relaxation exercises and tapes, practice yoga, meditation or have a massage to help relieve tension and anxiety, and join a self-help group and discuss your feelings and concerns. This can help you to feel less isolated. and diet There is increasing evidence that changes in your diet can help prevent depression occurring, or if you are depressed, can help in the treatment of your depression. Omega-3 Fatty Acid Research has shown a link between the amount of a fish people in different countries eat, and the level of depression. In Japan, where people eat on average 70 kg (150 lbs) of fish a year, the rate of depression is 0.12%. Whereas, in New Zealand, where people eat only 18kg (40lbs) of fish a year, the rate of depression is almost 50 times higher. It is though that a chemical found in fish - omega-3 fatty acid - may help your brain work more efficiently, so serotonin (which can boost your mood) has more of an effect on you. Fish that contains a lot of omega-3 fatty acid includes salmon, sardines and mackerel. Vegetarian alternatives include walnuts and tofu, and omega-3 food supplements are also available over-thecounter (OTC) from pharmacists' health shops. Protein and serotonin Serotonin is made up an amino acid 5-Hydroxy Tryptophan (5-HTP) which, in turn, is made from another amino acid called tryptophan. Both of these are found in protein-rich foods, such as meat, fish, beans and eggs. Foods also high in vitamin B, such as bananas and avocados, can be beneficial to your mood as they convert tryptophan into serotonin. By eating these types of food you are helping your body produce more serotonin and it can therefore boost your mood. Bad mood food Alcohol, caffeine, sugar, chocolate, cakes, biscuits, cheese and bread are the most common types of foods that cause low moods. Sugar is a major cause of altering mood because when you eat something sugary, your blood sugar level rises sharply which is followed, about an hour or so later, by a 'sugar low' as the amount of sugar in your blood decreases. This has a negative effect on your mood and energy level, leading to poor concentration, anxiety, irritability, aggression, tiredness and

11 Page 11 of 11 depression. NHS Institute for Innovation and Improvement