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Alcohol use disorder (AUD) is the most common co-occurring disorder in people with schizophrenia. Both biological factors and psychosocial factors are thought to contribute to this co-occurrence. Schizophrenia patients with AUD are more likely to have social, legal, and medical problems, compared with other people with schizophrenia. AUD also complicates the course and treatment of schizophrenia.

Schizophrenia is a severe and disabling psychiatric disorder characterized by persistent delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms such as the absence of emotional expression or a lack of motivation or initiative (American Psychiatric Association [APA] 1994). Alcohol use disorder¹ (AUD) (The term "alcohol use disorder" in this article refers to the disorder defined by criteria for alcohol abuse or dependence in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] [APA 1994]). The terms "alcohol use disorder" and "alcohol abuse" are used interchangeably in this article. The definitions for these terms vary among studies reviewed and are frequently based on earlier versions of the DSM.) commonly co-occurs with schizophrenia. This article reviews several aspects of AUD among people with schizophrenia, including the prevalence of this co-occurrence, biological and psychosocial factors that contribute to this relationship, correlated problems dually diagnosed people experience, the effects of AUD on the course and outcome of schizophrenia, treatment issues, and public policy implications. People with schizophrenia and AUD frequently abuse other substances as well. Current understanding of contributing factors, correlated problems, effect on course of illness, and treatment implications is similar for different substances of abuse.

Prevalence and Contributing Factors

Schizophrenia is frequently complicated by comorbid disorders such as medical illnesses, mental retardation, and substance abuse. Substance use disorder is the most frequent and clinically significant comorbidity in this population, and alcohol is the most common substance of abuse, other than nicotine (nicotine is much more prevalent than any other substance of abuse in this population) (Cuffel 1996). Undoubtedly, the availability of alcohol and the fact that it is legal contribute to its widespread abuse among people with schizophrenia as well as in the general population. The Epidemiologic Catchment Area (ECA) study² (The ECA study was a nationwide survey that used DSM-IV criteria to determine the prevalence of psychiatric disorders in the general population and among people in treatment.) found that 33.7 percent of people with a diagnosis of schizophrenia or schizophreniform disorder (a related disorder marked by the same symptoms as schizophrenia but lasting less than 6 months) also met the criteria for an AUD diagnosis at some time during their lives and that 47 percent met the criteria for any substance use disorder (excluding nicotine dependence) (Regier et al. 1990).

Rates of substance use disorder tend to be higher among males and among people of both genders and all ages in institutional settings, such as hospitals, emergency rooms, jails, and homeless shelters. This holds true for people with and without schizophrenia (Regier et al. 1990).

The high rates of AUD and other substance use disorders in people with schizophrenia appear to be determined by a complex set of factors (described below) (Mueser et al. 1998). People with schizophrenia probably use alcohol and other drugs for many of the same reasons as others in society, but several biological, psychological, and socioenvironmental factors have been hypothesized to contribute to this population's high rates of substance use disorders.

Biological Factors

There are three possible biological factors. First, many clinicians and researchers have asserted that people with schizophrenia use alcohol and other drugs to self-medicate in an attempt to alleviate the symptoms of schizophrenia or the side effects of the antipsychotic medications prescribed for schizophrenia (Chambers et al. 2001). Research evidence does not strongly support this view, however. For example, alcohol abuse often precedes schizophrenia; specific drugs of abuse are not selected in relation to specific symptoms; and various substances of abuse produce a range of different effects but generally exacerbate rather than relieve symptoms of schizophrenia (Chambers et al. 2001).

Second, the underlying neuropathological abnormalities of schizophrenia (i.e., the abnormalities in the brain that characterize schizophrenia) are thought to facilitate the positive reinforcing effects of substance use (Chambers et al. 2001). A common neurological basis for schizophrenia and for the reinforcing effects of substance use may predispose people to both conditions. This common basis involves the dysregulation of the brain chemical (i.e. neurotransmitter) dopamine. This would explain why people with schizophrenia prefer drugs such as nicotine and a class of antipsychotic medications that increase dopamine transmission in some areas of the brain. Of course, the reinforcing effects of alcohol use involve multiple neurotransmitter systems, and the mechanisms at work are not yet clear (Koob and Roberts 1999). The neurobiology of schizophrenia is similarly unclear (Chambers et al. 2001).

The third hypothesis suggests that people with schizophrenia are especially vulnerable to the negative psychosocial effects of substance use because the schizophrenia syndrome produces impaired thinking and social judgment and poor impulse control. Thus, even when using relatively small amounts of psychoactive substances, these people are prone to develop significant substance-related behavioral problems that qualify them for a diagnosis of substance use disorder (Mueser et al. 1998).

Psychological and Socioenvironmental Factors

Psychological and socioenvironmental factors also appear to contribute to the co-occurrence of schizophrenia and AUD. People with schizophrenia and AUD often report that they use alcohol and other drugs to alleviate the general dysphoria of mental illness, poverty, limited opportunities, and boredom; they also report that substance use facilitates the development of an identity and a social network (Dixon et al. 1990). An entire generation of adults with schizophrenia in the United States has grown up during the era of deinstitutionalization (Lamb and Bachrach 2001). Although residing predominantly in the community rather than in hospitals, these people still have had limited vocational, recreational, and social opportunities (caused by factors such as illness, stigma, and segregation). Further, they have experienced downward social drift into poor urban living settings, where they are regularly exposed to substance abuse and substance-abusing social networks (Lamb and Bachrach 2001).

Correlated Problems and The Effects of AUD on The Course and Outcome of Schizophrenia

Two general types of studies of the problems experienced by people with co-occurring schizophrenia and AUD are available. The first type, cross-sectional studies, collects data at one point in time. The second type, longitudinal studies, collects data at several points over a period of time. Cross-sectional studies indicate that AUD among people with schizophrenia is associated with numerous manifestations of bad outcomes and poor quality of life (referred to generally as poor adjustment), including increased recurrence of psychiatric symptoms, psychosocial instability, other substance use disorders, violence, victimization, legal problems, medical problems such as HIV infection and hepatitis, family problems, and institutionalization in hospitals and jails (Drake and Brunette 1998). People with schizophrenia and AUD are particularly prone to unstable housing situations and homelessness. Although these people often reject medications and outpatient treatment, they nevertheless represent a high cost to the treatment system because they receive a high rate of hospital-based services-relapse, as well as familial, psychosocial, legal, housing, and other crises force them into emergency care (Dickey and Azeni 1996).

The common explanation for these correlated problems is that alcohol use causes or exacerbates poor adjustment among people with schizophrenia. Many other factors could, however, explain the relationships between AUD and poor adjustment found in cross-sectional studies. For example, schizophrenia patients who abuse alcohol often abuse other substances, fail to take medications, and live in stressful circumstances without a strong support network, as described above. They may also have other inherent differences from schizophrenia patients without AUD, thereby confounding the comparison between schizophrenia patients with AUD and those without AUD.

Researchers are also accumulating longitudinal data regarding the course and outcome of co-occurring schizophrenia and AUD. Short-term studies lasting 1 year or less of patients in traditional mental health treatment systems indicate that they are prone to negative outcomes, such as continuing alcohol abuse or dependence, high rates of homelessness, disruptive behavior, psychiatric hospitalization, victimization, and incarceration. For example, one typical study of outpatients with schizophrenia found that those with co-occurring AUD had higher rates of hospitalization and depression compared with those with schizophrenia only (Cuffel and Chase 1994).

Several studies, including some studies that tracked participants' progress over time (rather than collecting data on patients' histories at some later point) indicate that dually diagnosed people who become abstinent (compared with those who do not) show more positive results in other related areas, such as lower psychiatric symptoms and decreased rates of hospitalization (Drake et al. 1996). For example, people in the ECA study with schizophrenia and AUD who attained abstinence had decreased rates of depression and hospitalization at 1-year followup (Cuffel 1996). In a long-term followup study of schizophrenia patients by Drake and colleagues (1998), those who attained stable abstinence showed dramatic improvements in many domains, including decreased symptoms, decreased institutionalization, increased psychosocial stability, and self-reported improvements in quality of life. These positive findings have fueled attempts to develop more effective interventions for AUD among schizophrenia patients. As described below, such interventions include those that integrate treatment for schizophrenia and for AUD.

Treatment

Historically, the mental health and substance abuse treatment systems in the United States have been separate, and traditional approaches to treating people with co-occurring disorders have involved parallel or sequential treatment in these separate systems. In practice, patients with co-occurring mental and substance use disorders have rarely received needed treatments (Watkins et al. 2001) and have generally experienced poor outcomes (Drake et al. 1996; Ridgely et al. 1987). As a result, there has been widespread endorsement by patients, clinicians, administrators, and researchers for integrating mental health and substance abuse services (Bellack and DiClemente 1999; Onken et al. 1997; Ries 1994). There is also accumulating research support for the effectiveness of the integrated treatment approaches that have evolved over the past two decades (Drake et al. 1998).

Integrated approaches to treatment for patients with schizophrenia and AUD are generally offered through the use of multidisciplinary treatment teams that provide outreach, comprehensive services, and stage-wise treatments (described below). Outreach is needed because these patients are often demoralized and reluctant to engage in treatment. Comprehensive services are vital because recovery involves building skills and supports to pursue a meaningful life rather than just managing symptoms or illnesses. Stage-wise treatment assumes that patients recover from two serious disorders over time, in stages, and with help from treatment providers. Patients with schizophrenia and AUD generally pass through four stages of treatment:

• Engagement, which involves building a trusting treatment relationship
• Persuasion, which entails developing motivation to manage both illnesses and pursue recovery
• Active treatment, which encompasses development of the skills and supports needed for illness management and recovery
• Relapse prevention, which involves strategies to avoid and minimize the effects of relapses (Osher and Kofoed 1989).

Although the need to provide integrated, multidisciplinary services is clear, the numerous specific treatments that are in use or in development need to be tested regarding their individual effectiveness and their effectiveness in combination (Drake et al. 2001). For example, specific individual, group, family, and self-help approaches to integrated treatment are described in the literature, but few studies validate or compare these different approaches. Similar comments pertain to potential psychopharmacologic treatments and to approaches to psychiatric rehabilitation. Several retrospective studies indicate that the antipsychotic medication clozapine may be particularly helpful to patients with schizophrenia and AUD, but the mechanisms of action for the effects on both illnesses are unclear, and controlled research is needed to establish the efficacy and effectiveness of this treatment (Green et al. 1999).

Several approaches to housing, social skills training, vocational services, money management, and supervision have also been recommended but not rigorously tested. Another important area of investigation is treatment for those patients who do not respond to standard outpatient approaches. Clinicians need to know which patients should be offered residential treatments, contingency management (i.e., providing positive consequences for desired behaviors and withholding those consequences or providing negative consequences for undesired behaviors), adjunctive medications, money management, or other second-line interventions (i.e., interventions for patients who do not respond to standard treatment) (Drake et al. 2001).

Public Policy

Although the testing and refinement of specific interventions, the development of treatment matching, and strategies to overcome nonresponsiveness are important issues, progress toward integrating mental health and substance abuse services has been minimal. Barriers exist at all levels (e.g., organizational, financial, and educational) and public policy at the Federal, State, regional, and local levels has thus far failed to promote widespread adoption of either integrated treatments for dual disorders or other evidence-based practices in the mental health and substance abuse treatment systems (Goldman et al. 2001). Clinicians, patients, and family members can advocate for effective services, but training and even successful demonstration programs will not be sustainable if policymakers do not eliminate restrictions and provide the incentives and reinforcements for evidence-based practices.

Summary and Conclusions

AUD and other substance use disorders are extremely common among patients with schizophrenia. Almost half of schizophrenia patients have a substance use disorder (when nicotine dependence is excluded) during their lifetime. The rate is probably even greater among high-risk groups, such as young men with a history of violence or homelessness, and among patients in acute care settings. In most geographic areas, alcohol is the most common substance of abuse (other than nicotine) among patients with schizophrenia, and alcohol abuse is correlated with poor concurrent adjustment and predictive of adverse outcomes such as higher rates of homelessness, hospitalization, and incarceration.

Current research indicates that integrating mental health and substance abuse treatments is more effective than offering services in parallel systems. Integrated treatments, generally delivered by multidisciplinary teams, emphasize outreach, comprehensiveness, and a stage-wise approach to treatment and recovery. Overcoming the barriers to the implementation of integrated treatments in routine health care settings is an immediate challenge. Specific psychosocial and pharmacological interventions also need further development and testing, particularly for patients who do not respond to basic integrated interventions.

References

American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: APA, 1994.

BELLACK, A.S., and DICLEMENTE, C.C. Treating substance abuse among patients with schizophrenia. Psychiatric Services 50:75-80, 1999.

CHAMBERS, A.; KRYSTAL, J.H.; and SELF, D.W. A neurobiological basis for substance abuse comorbidity in schizophrenia. Biological Psychiatry 50:71-83, 2001.

CUFFEL, B.J. Comorbid substance use disorder: Prevalence, patterns of use, and course. In: Drake, R.E., and Mueser, K.T., eds. Dual Diagnosis of Major Mental Illness and Substance Disorder: Recent Research and Clinical Implications. San Francisco: Jossey-Bass, 1996. pp. 93-105.

CUFFEL, B.J., and CHASE, P. Remission and relapse of substance use disorder in schizophrenia: Results of a one-year prospective study. Journal of Nervous and Mental Disease 182:342-348, 1994.

DICKEY, B., and AZENI, H. Persons with dual diagnosis of substance abuse and major mental illness: Their excess costs of psychiatric care. American Journal of Public Health 86:973-977, 1996.

DIXON, L.; HAAS, G.; WEIDEN, P.; et al. Acute effects of drug abuse in schizophrenic patients: Clinical observations and patients' self-reports. Schizophrenia Bulletin 16:69-79, 1990.

DRAKE, R.E., and BRUNETTE, M.F. Complications of severe mental illness related to alcohol and other drug use disorders. In: Galanter, M., ed. Recent Developments in Alcoholism. Volume 14. Consequences of Alcoholism. New York: Plenum Press, 1998. pp. 285-299.

DRAKE, R.E.; MUESER, K.T.; CLARK, R.E.; and WALLACH, M.A. The natural history of substance disorder in persons with severe mental illness. American Journal of Orthopsychiatry 66:42-51, 1996.

DRAKE, R.E.; MERCER-MCFADDEN, C.; MUESER, K.T.; et al. A review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin 24:589-608, 1998.

DRAKE, R.E.; ESSOCK, S.M.; SHANER, A.; et al. Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services 52:469-476, 2001.

GOLDMAN, H.H.; GANJU, V.; DRAKE, R.E.; et al. Policy implications for implementing evidence-based practices. Psychiatric Services 52:1591-1597, 2001.

GREEN, A.I.; STROUS, R.D.; ZIMMET, S.V.; and SCHILDKRAUT, J.J. Clozapine for co-morbid substance use disorder and schizophrenia: Do patients with schizophrenia have a reward deficiency syndrome that can be ameliorated by clozapine? Harvard Review of Psychiatry 6:287-296, 1999.

KOOB, G.F., and ROBERTS, A.J. Brain reward circuits in alcoholism. CNS Spectrums 4:23-37, 1999.

LAMB, H.R., and BACHRACH, L. Some perspectives on deinstitutionalization. Psychiatric Services 52:1039-1045, 2001.

MUESER, K.T.; DRAKE, R.E.; and WALLACH, M.A. Dual diagnosis: A review of etiological theories. Addictive Behaviors 23:717-734, 1998.

ONKEN, L.S.; BLAINE, J.D.; GENSER, S.; and HORTON, A.M.S., eds. Treatment of Drug-Dependent Individuals with Comorbid Mental Disorders. National Institute of Drug Abuse Research Monograph No. 172. Bethesda, MD: National Institute of Drug Abuse, 1997.

OSHER, F.C., and KOFOED, L.L. Treatment of patients with psychiatric and psychoactive substance abuse disorders. Hospital and Community Psychiatry 40:1025-1030, 1989.

REGIER, D.A.; FARMER, M.E.; RAE, D.S.; et al. Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study. JAMA: Journal of the American Medical Association 264:2511-2518, 1990.

RIDGELY, M.S.; OSHER, F.C.; and TALBOTT, J.A. Chronic Mentally Ill Young Adults with Substance Abuse Problems: Treatment and Training Issues. Baltimore, MD: University of Maryland Mental Health Policy Studies Center, 1987.

RIES, R.K. Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series 9. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, 1994.

WATKINS, K.E.; BURNAM, A.; KUNG, F.Y.; and PADDOCK, S. A national survey of care for persons with co-occurring mental and substance use disorders. Psychiatric Services 52:1062-1068, 2001.

National Institute of Mental Health
By Robert E. Drake, MD, PhD, and Kim T. Mueser, PhD
November 2002

Reviewed by athealth.com on February 2, 2014

Why Does It Occur and How Does It Fit in the Cycle of Violence?

Much has been written about spousal violence and its effect on children in families who witness such violence. More recently, dating violence among the high school population has been studied.

Depending on the methods used, studies have indicated that 20% to 50% of high school students have experienced violence in a dating relationship (Johnston, 1992, p. 331; Simons, Lin, & Gordon, 1998, p. 467; O'Keefe, 1997, p. 546).

In a recent study, Molidor, Tolman, and Kober (2000) looked at the rates of dating violence for high school boys and girls, as well as the circumstances leading to and the outcomes of dating violence. In questionnaires distributed to over 600 high school students, youth between 13 and 18 years of age were asked about the frequencies of any past dating violence and in their most recent or current dating relationship. The researchers discovered that 36.4% of the girls and 37.1% of the boys reported that they had experienced some physical violence in the dating relationship. The degree of violence reported differed by gender. Girls were more likely to be punched or forced to engage in sexual activity. Boys were more likely to be pinched, slapped, scratched, and kicked. Forty-two percent of the males and 43% of the females reported that the dating abuse occurred in a school building or on school grounds. Furthermore, 40% of the time when girls experienced abuse and 49% of the time when boys experienced abuse, someone else was present - either another individual or a group of people.

When asked about their reaction or response to the violence, boys' and girls' responses differed markedly. Over half of the boys said that they laughed at the physical altercation. One-third of the boys reported ignoring it. Forty percent of the girls reported crying, and nearly 36% reported fighting back when confronted with violence in a dating relationship.

When asked for reasons why the abuse occurred, 17.1% of the boys reported that the violence occurred because they had been making sexual advances to their partner, whereas 37% of the girls cited their partner's sexual advances as the reason they were subject to physical violence. Nearly 37% of the boys who experienced physical abuse reported that they were drunk at the time. This figure was cited differently by girls - 55% of the girls said that their partners were drunk when the violent incident occurred. Nine percent of the girls reported being drunk when physical abuse occurred.

Students were asked whom they told about the incidence of dating violence. No significant differences between the sexes were found in this area. Fewer than 3% of the students reported the incident to someone in authority (e.g., police officer, counselor, or teacher). Six percent of the physically or sexually abused high school students told a family member, 61% told a friend, and over 30% told no one about the abusive incident.

Molidor, Tolman, and Kober (2000, p. 4) suggest that boys often begin abusive behavior toward their female partners before they are adults, which suggests the need to intervene during adolescence to end "gendered violence." Other research supports the relationship between adolescent dating violence and later spousal abuse (Simons, Lin, & Gordon, 1998, p. 467; Johnston, 1992, p. 5; Foshee et al., 2000, p. 5). The pattern of abuse between high school dating partners and later marital partners continues to have deleterious effects. Research indicates that children who are exposed to family violence are more likely to use aggression in their relationships with peers and romantic partners later in life (Simons, Lin, & Gordon, 1998, p. 468; Johnston, 1992, p. 5). Hence the cycle of violence continues.

Interrupting this harmful cycle is clearly in the best interest of all. How can we influence patterns of adolescent dating violence? What are some of the predictors of using violence in dating relationships?

In a study of 1,012 racially, ethnically, and socioeconomically diverse students enrolled in various high schools in Los Angeles, O'Keefe (1997) found that violence in dating relationships was a frequent occurrence: 43% of the females and 39% of the males reported that they had inflicted some form of physical aggression on their dating partners at least once (p. 555). In considering the factors that best predicted inflicting dating violence, O'Keefe found that being a recipient of violence was the strongest predictor of inflicting dating violence. In other words, acts of violence create a risk for a violent response or for future violent acts. O'Keefe found this predictor to be stronger for females, who were more likely than males to hit in retaliation or self-defense (p. 563).

Other strong predictors of dating violence included the justification or acceptance of dating violence (those students who viewed violence as an appropriate response to conflict were more likely to behave violently), the presence of conflict in the dating relationships, alcohol or drug use, and witnessing interparental violence. O'Keefe found this last predictor - viewing spousal violence - stronger for males than females (p. 564).

Interrupting the cycle of abusive behavior is difficult. Research suggests that education is most effective in altering abuse in relationships when it emphasizes that violence is not an acceptable or normal part of interpersonal relationships (McNulty, Heller, & Binet, 1997, p. 26). Many schools are incorporating curriculum that addresses what constitutes normal levels of conflict in relationships, what constitutes violence, and what skills are needed for resolving conflict within a relationship nonviolently (McNulty, Heller, & Binet, 1997).

Parents play a critical role in influencing adolescent dating behaviors. They do so by the example they provide in managing their own conflict (Patten, 2000). They do so in the broad pattern of parenting they use, which can either increase or decrease the probability of their child using aggression with others (Steinberg & Levine, 1997; Darling, 1999). Finally, parents help to interrupt a pattern of violence by intervening when they suspect their adolescent is involved in an abusive dating relationship (Steinberg & Levine, 1997, pp. 339-340).

Sources

Darling, Nancy. (1999). Parenting style and its correlates. ERIC Digest. Champaign, IL: ERIC Clearinghouse on Elementary and Early Childhood Education. (ERIC Document No. ED427896).

Foshee, Vangie A.; Bauman, Karl, E.; Arriaga, Ximena B.; Helms, Russell W.; Koch, Gary G.; & Linder, Fletcher, G. (2000). The safe dates project. Prevention Researcher, 7(1), 5-7.

Johnston, Janet (Ed.). (1992). Violence and hate in the family and neighborhood: New perspectives, policy and programs. Corte Madera, CA: Center for the Family in Transition. (ERIC Document No. ED369536)

McNulty, Raymond J.; Heller, Daniel A.; & Binet, Tracy. (1997). Confronting dating violence. Educational Leadership, 55(2), 26-28. (ERIC Journal No. EJ552001)

Molidor, Christian; Tolman, Richard M.; & Kober, Jennifer. (2000). Gender and contextual factors in adolescent dating violence. Prevention Researcher, 7(1), 1-4, 10.

O'Keefe, Maura. (1997). Predictors of dating violence among high school students. Journal of Interpersonal Violence, 12(4), 546-568. (ERIC Journal No. EJ560619)

Patten, Peggy. (2000). Marital relationships, children, and their friends: What's the connection? An interview with E. Mark Cummings. Parent News [Online], 6(3). [2000, May 14].

Simons, Ronald L.; Lin, Kuei-Hsiu; & Gordon, Leslie C. (1998). Socialization in the family of origin and male dating violence: A prospective study. Journal of Marriage and the Family, 60(2), 467-478. (ERIC Journal No. EJ579059)

Steinberg, Laurence, & Levine, Ann. (1997). You and your adolescent: A parent's guide for ages 10-20. New York: HarperCollins. (ERIC Document No. ED408108)

Source: Patten, Peggy. (2000). Dating Violence: Why does it occur and
how does it fit in the cycle of violence? Parent News [Online], 6(4).

Reviewed by athealth.com on February 2, 2014

Biting behavior in young children is a cause of concern for parents and child caregivers. Although little empirical research focuses specifically on this topic (Claffey, Kucharski, & Gratz, 1994), a variety of practical resources offer some guidance to parents and caregivers. This report discusses (1) why young children bite, (2) how common biting problems are, (3) what interventions might be considered, and (4) how teachers or caregivers can interact with and involve parents in dealing with biting behavior.

Why do young children bite?

The literature suggests that biting may be a normal developmental phase for infants and toddlers, with virtually no long-lasting developmental significance. Once a child turns 3 years old, however, biting may indicate other behavioral problems, especially if the biting incidents are frequent. Because of the developmental nature of most biting, experts stress that biting is not something to blame on the child, parents, or teachers (Greenman & Stonehouse, 1994).

Infants

For infants, developmental theorists suggest that biting is probably a form of exploration--infants use their mouths to explore because it is one of the most developed parts of their bodies. Biting in infants may also be a primitive form of communication; it is likely that the infant does not connect biting to pain experienced by others (Claffey, Kucharski, & Gratz, 1994; Marlowe, 1999; Oesterreich, 1995). Infants also are impulsive and lack self-control; some babies may bite simply because something is there to bite; others bite when they are excited or over-stimulated (e.g., music stimulates the infant, who then bites because he or she is so happy and excited) (Greenman & Stonehouse, 1994). Thus, the literature concludes that infants bite because they want to smell and touch objects, experiment with cause and effect, or relieve teething pain (the National Association for the Education of Young Children [NAEYC, 1996] suggests offering infants who are teething chew toys, frozen bagels, or other safe items.

Toddlers

Oesterreich (1995) and other theorists believe that, as with infants, biting in toddlers between 12 and 36 months old is a form of communication (i.e., to communicate frustration while learning social, language, and self-control skills). Oesterreich also posits that toddlers seldom plan ahead, but rather that they see and act on what they are experiencing at the moment. Toddlers, Oesterreich claims, do not have the language necessary to control a situation, or their attempts at communication are not understood or respected. Biting becomes a powerful way to communicate with and control others and the environment. Biting demonstrates autonomy and is a quick way to get a toy or attention (Oesterreich, 1995). Many toddlers display extreme ranges of emotions, both happy and sad, and they lack labels for communicating these emotions. Too many challenges (from activities that are too difficult), demands, wants, and obstacles can anger and frustrate toddlers and may lead to biting. Many toddlers do not yet understand sharing or that touch can hurt, and they need to learn other ways to communicate besides biting (Claffey, Kucharski, & Gratz, 1994).

Child caregivers have noted that toddlers may also bite when they experience a stressful event, a particularly distressing lack of routine, or inadequate adult interaction. According to Claffey, Kucharski, and Gratz (1994), toddlers may be more apt to bite if they have not interacted with adults for more than 5 minutes. Other toddlers may bite as a self-defense strategy, or they may simply be imitating other toddlers who bite (Marlowe, 1999; NAEYC, 1996).

Preschoolers

Occasional or rare biting from preschoolers may occur for some of the same reasons as it does for infants and toddlers--to exert control over a situation, for attention, as a self-defense strategy, or out of extreme frustration and anger. Frequent biting after a child turns 3, however, may indicate other behavior problems, because by that time many children have the communication skills necessary to relate their needs without biting. Kranowitz (1992) speculates that biting may also be caused by sensory integration dysfunction in a small number of young children. She suggests that developmental screening for preschoolers may be useful to identify children with tactile dysfunction. (These children may respond negatively to touch sensations, becoming anxious, hostile, or aggressive. They may be under- or over-responsive to touch, or react negatively when others are close. Light touches from behind may be particularly distressing, leading, in some situations, to biting.)

Incidence of biting behaviors

The National Association for the Education of Young Children (1996) estimates that 1 out of 10 toddlers/2-year-olds engages in biting behaviors. Garrard, Leland, and Smith (1988) examined the injury log of one large (224 children) early childhood center. They also studied the biographical information about each child filled out by the parent at the time of admission and financial records to document enrollment. They determined that 347 bites occurred during the study year. Seventy-two bites were attributed to infants, 195 to toddlers, and 80 to preschoolers. The highest incidence of biting behavior occurred in September, and male toddlers initiated most episodes.

Of the 224 children enrolled in the center, 29 were infants (0-16 months), 62 were toddlers (16-30 months), and 133 were preschoolers (30-72 months). Toddlers were the most likely to bite; each toddler on average initiated 3.13 bites per 100 days of enrollment (the figure was 3.66 for males and 2.3 for girls). The corresponding figure for infants was .7129 bites and, for preschoolers, .5611 bites. No gender differences were noted in the infant and preschooler group. Finally, no demographic characteristic predicted children who were bitten vs. those not bitten other than number of days of enrollment (newer children were more likely to be bitten) (Garrard, Leland, & Smith, 1988).

What to do when biting occurs

No research was located for this report that evaluated different strategies for handling biting incidents, but the literature does present some practical ideas and strategies for dealing with a biting child offered by experts, child caregivers, and parents.

Respond immediately

Infants may not yet understand the difference between biting a toy and biting a person, so a repeated message in an honest tone of voice that conveys pain (saying "Ouch, that hurt me, Joey!") can help teach infants age 4 months and older not to bite others (Marlowe, 1999).

The literature strongly suggests that caregivers and parents not bite the child back as a punishment or to show the child how it feels to be bitten. Biting back communicates to the child that violence is acceptable (Claffey, Kucharski, & Gratz, 1994; Garcia, 1999; NAEYC, 1996). Because theorists think that biting may be related to the child's developmental stage, punishment in general is not advised either at home or in a child care center (Greenman & Stonehouse, 1994). Instead, experts recommend focusing attention on the victim, shielding the victim from the biter, initiating first aid measures as necessary, and consoling the victim (Claffey, Kucharski, & Gratz, 1994; Greenman, 1995).

Garcia (1999) and Greenman and Stonehouse (1995) suggest that biters who have reached age 2 or older may benefit from assisting in the first aid process. The biter can assist the victim by demonstrating "gentle touching," having the biter rub the victim's arm, and generally assisting with taking care of the victim to teach nurturing behavior (without letting these activities become a game). Other sources recommend that biters should be removed from the situation without dramatic movements, attention, or an emotional response that could provide negative reinforcement to the biter. Parents and caregivers can tell the biter that "biting is not OK," "I can't let you hurt your friends," etc. Toddlers in particular may not understand time-out, but caregivers need to make sure that the biter is not near other children until he or she has calmed down and can be redirected to other play (Garcia, 1999; Greenman, 1995; NAEYC, 1996).

Stress communication skills

Greenman (1995) suggests that emphasis be placed on teaching biters to develop and use their expressive communication skills instead of biting, so that they can learn to "use words" to express their feelings. Good caregivers consistently promote the child's use of language to enhance cognitive development, and some experts believe that promoting children's language development is also helpful to reduce biting behaviors. For example, if another child is taking a toy away from a child who has a history of biting, caregivers can teach the potential biter to say "stop," "mine," etc., and tell the child "We don't bite people, we bite food" or "It hurts when you bite" (Hewitt, 1995). Claffey, Kucharski, and Gratz (1994) and Legg (1993) suggest that using positive language to tell the child to "touch gently" rather than "don't hit/bite" can be helpful. They also suggest that caregivers can help children verbalize their feelings by saying "You look angry, Peter. Tell Amy to stop pulling, you don't like that." Caregivers and parents should try to be specific with their language. Instead of saying "Stop being mean to Peter," for example, they can say "Peter is angry because you are taking his truck." Experts also recommend consistently teaching the child to say "no" to other children rather than biting (Todd, 1996).

Examine context

Experts recommend that efforts be made to examine the pattern of biting incidents to determine if factors such as crowding, over-stimulation, lack of toys, lack of attention or supervision, or other factors seem to precede biting episodes. Garcia (1999) suggests that caregivers become adept at observing the child's physical state and noticing whether factors such as new teeth or other kinds of pain on a given day seem to be associated with increased biting episodes. Caregivers might think about whether children bite when their bowels are irregular, when they are hungry, or when they are sleepy. Some experts believe that emotions and stress inducers such as a new baby in the house may also be associated with an increase in biting episodes for individual children (Garcia, 1999).

Create positive physical and learning environments

If caregivers determine that a child is biting more than once a day for more than a week, experts suggest that it is probably time to develop a plan to decrease the biting. They recommend attempting to break the cycle by varying activities and the child's schedule. Legg (1993) suggests that it may help to break up the density of the toddlers in the room to enhance program quality (one group goes outside, another stays in the room, etc.). Experts suggest tracking these changes so that there is a written record that can help to determine the context of the biting incidents and to show the results of interventions (Claffey, Kucharski, & Gratz, 1994; Hewitt, 1995).

Greenman (1995), Hewitt (1995), and NAEYC (1996) suggest that attempting to maintain a consistent routine, developing and maintaining rituals, and finding effective ways of calming children after energetic activity or during transition times (using calming music, relaxed/calming physical contact, etc.) may serve to relieve the conditions that lead to biting episodes. These experts also recommend avoiding grouping biters and previous victims together to the extent possible.

Several experts (e.g., Claffey, Kucharski, & Gratz, 1994; Garcia, 1999; Greenman, 1995) suggest that caregivers examine the center environment and try to minimize congestion and confusion, competition for toys and adult attention, frustration, and boredom. Young children do better in small groups, according to these experts, so spreading out activities and staff may help reduce undesirable behaviors. They also suggest the following strategies for caregivers:

• Be aware of the children's favorite toys and educational materials and duplicate these (because sharing is not always in the toddler's behavioral repertoire!).
• Provide a variety of options and motor/sensory choices (e.g., make the toys and climbing structures challenging but not so frustrating that the children become angry or bored). Adjust the schedule so that the children eat and nap when they are beginning to get hungry and tired rather when these conditions become extreme.
• Find ways to strengthen the sense of security/stability in the environment.
• Maintain a consistent routine that minimizes surprises for children.
• Ensure prime times with the child's favorite primary caregiver.
• Develop/maintain group rituals.

Claffey, Kucharski, and Gratz (1994) detail other environmental factors to consider, such as creating a balance of open and closed spaces so that the children may move about freely but also feel protected and not feel overwhelmed. They suggest that counters and shelves be low so that the children are always kept in sight. Colors should be chosen carefully so that the overall color environment is not too stimulating. Noise-absorbing materials should be used so that the environment offers a sense of warmth and security. Materials can be open-ended so they may be used in many different ways to accommodate differing abilities (choosing blocks that can be stacked, sorted, classified, etc.).

Educate teachers and caregivers

Legg (1993) suggests that teachers and caregivers need to understand why children bite and the range of developmental issues that arise when toddlers are in group care. They should understand that very young children really are not developmentally ready to share, and that toddlers communicate physically before they are ready to use language. Because their social conscience and expressive communication skills are limited, toddlers may tend to shove, push, and bite. Claffey, Kucharski, and Gratz (1994) note that properly trained caregivers will be able to engage in positive guidance to show the children in their care how to play safely and to be considerate of others. Caregivers also must become adept at mediating disputes. They should anticipate problem situations and stay alert. If a particular child has difficulty in transitions, for example, the caregiver should stay close to the child and praise positive behavior, especially for children who bite. Caregivers can teach children age-appropriate ways to control themselves, which will encourage confidence and serve to guide children who bite toward self-control and away from biting. NAEYC (1996) suggests that the key to successful management of biting is understanding--for kids and adults alike. Staff at center-based programs need to recognize that biting is as normal and natural as toileting and tantrums, yet accept their responsibility to provide and maintain a safe environment (Greenman & Stonehouse, 1994).

Plan for biting epidemics

When a rash of biting incidents occurs in a center, Greenman (1995), Legg (1993), and Hewitt (1995) suggest that the following steps be taken:

• Meet with the director and room staff.
• Chart every occurrence and indicate location, time, participant behaviors, etc.
• Evaluate the immediate staff response to insure appropriateness (comforting bitten child and treating injury, providing a cool, firm disapproving response to the biter that does not inadvertently reinforce the behavior).
• Determine the context of the biting incidents: analyze, chart, and profile.
• Shadow children who have a biting tendency--anticipate biting situations and teach non-biting responses, adapting the program as necessary. Staff might shadow a severe biter for 2 weeks to prevent the behavior, because there is some evidence that if staff can prevent biting during this time period, the behavior will dissipate.
• If necessary, briefly place young children who bite in a crib or playpen to contain the child who is engaging in frequent biting, if the shadowing teacher has to do something else.
• Shadow children who tend to be bitten and anticipate potential biting situations; teach children who get bitten responses that will minimize the chance of their becoming victims.
• Consider early transition to another room for children who bite frequently, because the older children are better able to defend themselves.
• Extreme biting epidemics may require extra help from a consultant, parent educator, or counselor, especially if the behavior occurs daily or persists.

Parent Communication

Much of the literature that is focused on issues related to biting also addresses communicating with and involving parents. Most experts stress confidentiality; they recommend that teachers or directors NOT reveal the identity of the child who is biting to parents of other children.

Instead, experts suggest that child caregivers assure the parents that they are aware of the problem and are working toward solutions, but that all children are capable of having problems with biting. Parents should know that biting is a normal occurrence for many children in group care situations, particularly when they are in the toddler stage (Greenman & Stonehouse, 1994; Legg, 1993; Todd, 1996). These authors also recommend that parents be apprised of the possibility of biting incidents occurring in child care facilities during the initial intake process, or when infants are making the transition into the toddler room.

Legg (1993) also recommends that apologizing to family members is not an effective strategy, because an apology implies that there is a foolproof way to prevent the incidents. Instead, she suggests relating to the parents what is being done to insure the safety of all of the children. She also recommends focusing on what first aid treatments are used when incidents occur and what else is being done for children who are bitten.

As explained by Greenman and Stonehouse (1994), in extreme cases, termination or suspension of the biting child from a center may become necessary. The center should have a policy that offers guidance related to how long a severe biting problem can be allowed to continue. It is important that the parents of the biter be notified early of this possibility so that they can begin to make inquiries regarding alternate child care arrangements. Legg (1993) suggests that in many cases enrollment may only need to be temporarily suspended until the child improves his or her communication skills.

Claffey, Kucharski, and Gratz (1994) and NAEYC (1996) recommend that caregivers try to determine whether biting is occurring at home. Breaking the biting pattern will be difficult in an early childhood center if biting is allowed to occur at home without the same formal interventions being applied at the center. Marlowe (1999) advocates teaching parents to offer choices so that the child is given power and control at least a few times a day. Caregivers can keep parents informed about their child's favorite toy, what happened in the school day, etc. Overall, experts note that it is essential to maintain positive relationships with parents during biting outbreaks, to keep parents informed of the strategies being employed, to empathize with parents of both biters and victims regarding their feelings of helplessness related to the safety of their children, and to communicate to parents the staff training and intervention efforts that are occurring to remedy the problem (Greenman, 1995; Greenman & Stonehouse, 1994; Legg, 1993).

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Conclusion

Understanding the developmental factors that contribute to biting behavior can help parents and caregivers make environmental or programmatic changes as necessary to minimize the behavior; caregivers need to provide accurate information to parents (Reguero de Atiles, Stegelin, & Long, 1997). Guidance to children who bite should be provided with the goal of helping children develop inner control of their feelings and actions. A quick and consistent response at home and in the center can help children who bite learn to express their feelings in words so that they can become better able to control their behavior (Claffey, Kucharski, & Gratz, 1994; Garcia, 1999).

References

Claffey, Anne E.; Kucharski, Laura J.; & Gratz, Rene R. (1994). Managing the biting child. Early Child Development and Care, 99, 93-101. (ERIC Journal No. EJ486889)

Garcia, Veronica. (1999). Understanding and preventing toddler biting. Texas Child Care, 23(1), 12-15. (ERIC Journal No. EJ606990)

Garrard, J.; Leland, N.; & Smith, D. K. (1988). Epidemiology of human bites to children in a day-care center. American Journal of Diseases in Children, 142(6), 643-650.

Greenman, Jim. (1995). Reality bites (frequently): Biting at the center--Part 2. Child Care Information Exchange, 101, 65-67. (ERIC Journal No. EJ503564)

Greenman, Jim, & Stonehouse, Anne Willis. (1994). Reality bites: Biting at the center--Part 1. Child Care Information Exchange, 99, 85-88. (ERIC Journal No. EJ489936)

Hewitt, Deborah. (1995). So this is normal too? Teachers and parents working out developmental issues in young children. St. Paul, MN: Redleaf Press. (ERIC Document No ED391589).

Kranowitz, Carol Stock. (1992). Catching preschoolers before they fall: A developmental screening. Child Care Information Exchange, 84, 25-29. (ERIC Journal No. EJ443462)

Legg, Jackie. (1993). "What's a little bite among friends?" Child Care Information Exchange, 92, 41-43. (ERIC Journal No. EJ467457).

Marlowe, Dana. (1999). The stages of biting. Montessori Life, 11(2), 33-34. (ERIC Journal No. EJ584452).

National Association for the Education of Young Children. (1996). Biters: Why they do it and what to do about it [Online]. Washington, DC: Author.
Available: http://www.kidsource.com/kidsource/content3/biters.p.t.4.html.

Oesterreich, Lesia. (1995). Biting hurts [Online]. In L. Oesterreich, Bess Gene Holt, & Shirley Karas, Iowa family child care handbook (pp. 239-242). Ames: Iowa State University Extension.
Available: http://www.nncc.org/Guidance/bit.hurt.html.

Reguero de Atiles, Julia T.; Stegelin, Delores A.; & Long, Janie K. (1997). Biting behaviors among preschoolers: A review of the literature and a survey of practitioners. Early Childhood Education Journal, 25(2), 101-105.(ERIC Journal No. EJ558652)

Todd, Christine M. (1996). When children bite. Day care center connections [Online], 1(6), 3-4. Urbana-Champaign: University of Illinois Cooperative Extension Service.
Available: http://www.nncc.org/Guidance/dc16_children.bite.html.

ERIC Clearinghouse on Elementary and Early Childhood Education
Authors: Ron Banks and Sojin Yi
2002 (Last updated June 2004)

Page last modified or reviewed by athealth.com on February 2, 2014

Overweight and Obesity Among Adults

More than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are obese. During 1980-2008, obesity rates doubled for adults and tripled for children. During the past several decades, obesity rates for all population groups - regardless of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region - have increased markedly.

Overweight

Overweight and obesity are both labels for ranges of weight that are greater than what is generally considered healthy for a given height. The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems.

Definitions for Adults

For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the "body mass index" (BMI). BMI is used because, for most people, it correlates with their amount of body fat.

• An adult who has a BMI between 25 and 29.9 is considered overweight.
• An adult who has a BMI of 30 or higher is considered obese.

It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as overweight even though they do not have excess body fat. For more information about BMI, visit Body Mass Index. Body Mass Index Other methods of estimating body fat and body fat distribution include measurements of skinfold thickness and waist circumference, calculation of waist-to-hip circumference ratios, and techniques such as ultrasound, computed tomography, and magnetic resonance imaging (MRI). Definitions for Children and Teens

For children and teens, BMI ranges above a normal weight have different labels (overweight and obese). Additionally, BMI ranges for children and teens are defined so that they take into account normal differences in body fat between boys and girls and differences in body fat at various ages. For more information about BMI for children and teens (also called BMI-for-age), visit BMI for Children and Teens.

Risk Factors Associated With Childhood Obesity

Health risks now

Childhood obesity can have a harmful effect on the body in a variety of ways. Obese children are more likely to have

• High blood pressure and high cholesterol, which are risk factors for cardiovascular disease (CVD). In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more.
• Increased risk of impaired glucose tolerance, insulin resistance and type 2 diabetes.
• Breathing problems, such as sleep apnea, and asthma.
• Joint problems and musculoskeletal discomfort.
• Fatty liver disease, gallstones, and gastro-esophageal reflux (i.e., heartburn).
• Obese children and adolescents have a greater risk of social and psychological problems, such as discrimination and poor self-esteem, which can continue into adulthood.

Health risks later

Obese children are more likely to become obese adults. Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers.

If children are overweight, obesity in adulthood is likely to be more severe.

References

1.Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Supplement December 2007:S164 - S192.

2.Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150(1):12 - 17.e2.

3.Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics. 2005;116(1):e125 - 144.

4.Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. May 15 2010;375(9727):1737 - 1748.

5.Sutherland ER. Obesity and asthma. Immunol Allergy Clin North Am. 2008;28(3):589 - 602, ix.

6.Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics. Jun 2006;117(6):2167 - 2174.

7.Dietz W. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics 1998;101:518 - 525.

8.Swartz MB and Puhl R. Childhood obesity: a societal problem to solve. Obesity Reviews 2003; 4(1):57 - 71.

9.Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. May 2010;91(5):1499S - 1505S.

10.Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;37(13):869 - 873.

11.Serdula MK, Ivery D, Coates RJ, Freedman DS. Williamson DF. Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167 - 177.

12.National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 1998.

13.Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood overweight to coronary heart disease risk factors in adulthood: The Bogalusa Heart Study. Pediatrics 2001;108:712 - 718.

Content source: Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion
Page last updated: April 26, 2011

Reviewed by athealth.com February 3, 2014

 

What is depression?

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better.

Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment. Intensive research into the illness has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling disorder.

What are the different forms of depression?

There are several forms of depressive disorders. The most common are major depressive disorder and dysthymic disorder.

Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once–pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.

Dysthymic disorder, also called dysthymia, is characterized by long–term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include:

Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions.

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.¹

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.²

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs (e.g., mania) to extreme lows (e.g., depression). Visit the NIMH website for more information about bipolar disorder.

What are the signs and symptoms of depression?

People with depressive illnesses do not all experience the same symptoms. The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness.

Symptoms include:

• Persistent sad, anxious or "empty" feelings
• Feelings of hopelessness and/or pessimism
• Feelings of guilt, worthlessness and/or helplessness
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early–morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

What illnesses often co-exist with depression?

Depression often co–exists with other illnesses. Such illnesses may precede the depression, cause it, and/or be a consequence of it. It is likely that the mechanics behind the intersection of depression and other illnesses differ for every person and situation. Regardless, these other co–occurring illnesses need to be diagnosed and treated.

Anxiety disorders, such as post–traumatic stress disorder (PTSD),obsessive–compulsive disorder, panic disorder, social phobia and generalized anxiety disorder, often accompany depression.^3,4 People experiencing PTSD are especially prone to having co-occurring depression. PTSD is a debilitating condition that can result after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military combat.

People with PTSD often re–live the traumatic event in flashbacks, memories or nightmares. Other symptoms include irritability, anger outbursts, intense guilt, and avoidance of thinking or talking about the traumatic ordeal. In a National Institute of Mental Health (NIMH)–funded study, researchers found that more than 40 percent of people with PTSD also had depression at one-month and four-month intervals after the traumatic event.⁵

Alcohol and other substance abuse or dependence may also co–occur with depression. In fact, research has indicated that the co–existence of mood disorders and substance abuse is pervasive among the U.S. population.⁶

Depression also often co–exists with other serious medical illnesses such as

• heart disease
  
• stroke
  
• cancer
  
• hiv/aids
  
• diabetes
  
• Parkinson's disease

Studies have shown that people who have depression in addition to another serious medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co–existing depression.7 Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co–occurring illness.⁸

What causes depression?

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior appear to function abnormally. In addition, important neurotransmitters–chemicals that brain cells use to communicate–appear to be out of balance. But these images do not reveal why the depression has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well.9 Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.¹⁰

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

How do women experience depression?

Depression is more common among women than among men. Biological, life cycle, hormonal and psychosocial factors unique to women may be linked to women's higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the "baby blues," but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression often have had prior depressive episodes.

Some women may also be susceptible to a severe form of premenstrual syndrome (PMS), sometimes called premenstrual dysphoric disorder (PMDD), a condition resulting from the hormonal changes that typically occur around ovulation and before menstruation begins. During the transition into menopause, some women experience an increased risk for depression. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.¹¹

Finally, many women face the additional stresses of work and home responsibilities, caring for children and aging parents, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.

How do men experience depression?

Men often experience depression differently than women and may have different ways of coping with the symptoms. Men are more likely to acknowledge having fatigue, irritability, loss of interest in once–pleasurable activities, and sleep disturbances, whereas women are more likely to admit to feelings of sadness, worthlessness and/or excessive guilt.^12,13

Men are more likely than women to turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, irritable, angry and sometimes abusive. Some men throw themselves into their work to avoid talking about their depression with family or friends, or engage in reckless, risky behavior. And even though more women attempt suicide, many more men die by suicide in the United States.¹⁴

How do older adults experience depression?

Depression is not a normal part of aging, and studies show that most seniors feel satisfied with their lives, despite increased physical ailments. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief.¹⁵

In addition, older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what some doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body's organs, including the brain. Those with vascular depression may have, or be at risk for, a co–existing cardiovascular illness or stroke.¹⁶

Although many people assume that the highest rates of suicide are among the young, older white males age 85 and older actually have the highest suicide rate. Many have a depressive illness that their doctors may not detect, despite the fact that these suicide victims often visit their doctors within one month of their deaths.¹⁷

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both.18 Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults.¹⁹ Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.^20,21

How do children and adolescents experience depression?

Scientists and doctors have begun to take seriously the risk of depression in children. Research has shown that childhood depression often persists, recurs and continues into adulthood, especially if it goes untreated. The presence of childhood depression also tends to be a predictor of more severe illnesses in adulthood.²²

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to accurately diagnose a young person with depression.

Before puberty, boys and girls are equally likely to develop depressive disorders. By age 15, however, girls are twice as likely as boys to have experienced a major depressive episode.²³

Depression in adolescence comes at a time of great personal change–when boys and girls are forming an identity distinct from their parents, grappling with gender issues and emerging sexuality, and making decisions for the first time in their lives. Depression in adolescence frequently co–occurs with other disorders such as anxiety, disruptive behavior, eating disorders or substance abuse. It can also lead to increased risk for suicide.^22,24

An NIMH–funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option.25Other NIMH–funded researchers are developing and testing ways to prevent suicide in children and adolescents, including early diagnosis and treatment, and a better understanding of suicidal thinking.

How is depression detected and treated?

Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.

The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer the patient to a mental health professional.

The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should discuss any family history of depression, and get a complete history of symptoms, e.g., when they started, how long they have lasted, their severity, and whether they have occurred before and if so, how they were treated. He or she should also ask if the patient is using alcohol or drugs, and whether the patient is thinking about death or suicide.

Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.

Medication

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.

The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of antidepressants, such as tricyclics–named for their chemical structure–and monoamine oxidase inhibitors (MAOIs) because they tend to have fewer side effects. However, medications affect everyone differently. No one–size–fits–all approach to medication exists. Therefore, for some people, tricyclics or MAOIs may be the best choice.

People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines and substances.

For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit–forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, patients should be open to trying another. NIMH–funded research has shown that patients who did not get well after taking a first medication increased their chances of becoming symptom–free after they switched to a different medication or added another medication to their existing one.^26,27

Sometimes stimulants, anti–anxiety medications, or other medications are used in conjunction with an antidepressant, especially if the patient has a co–existing mental or physical disorder. However, neither anti–anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.

What are the side effects of antidepressants?

Antidepressants may cause mild and often temporary side effects in some people, but they are usually not long–term. However, any unusual reactions or side effects that interfere with normal functioning should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache–usually temporary and will subside.
• Nausea–temporary and usually short–lived.
• Insomnia and nervousness (trouble falling asleep or waking often during the night)– may occur during the first few weeks but often subside over time or if the dose is reduced.
• Agitation (feeling jittery).
• Sexual problems–both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.

Tricyclic antidepressants also can cause side effects including:

• Dry mouth - it is helpful to drink plenty of water, chew gum, and clean teeth daily.
• Constipation - it is helpful to eat more bran cereals, prunes, fruits, and vegetables.
• Bladder problems – emptying the bladder may be difficult, and the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected. The doctor should be notified if it is painful to urinate.
• Sexual problems – sexual functioning may change, and side effects are similar to those from SSRIs.
• Blurred vision – often passes soon and usually will not require a new corrective lenses prescription.
• Drowsiness during the day–usually passes soon, but driving or operating heavy machinery should be avoided while drowsiness occurs. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

FDA Warning on Antidepressants

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information from the FDA can be found on their Web site at www.fda.gov

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.28 The study was funded in part by the National Institute of Mental Health.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.

What about St. John's wort?

The extract from St. John's wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of the top-selling botanical products.

To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression.29 Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

Psychotherapy

Several types of psychotherapy – or "talk therapy" – can help people with depression.

Some regimens are short–term (10 to 20 weeks) and other regimens are longer–term, depending on the needs of the individual. Two main types of psychotherapies–cognitive–behavioral therapy (CBT) and interpersonal therapy (IPT)-have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence.²⁵ Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.²¹

Electroconvulsive Therapy

For cases in which medication and/or psychotherapy does not help alleviate a person's treatment–resistant depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. A patient typically will undergo ECT several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Although some patients will need only a few courses of ECT, others may need maintenance ECT, usually once a week at first, then gradually decreasing to monthly treatments for up to one year.

ECT may cause some short-term side effects, including confusion, disorientation and memory loss. But these side effects typically clear soon after treatment. Research has indicated that after one year of ECT treatments, patients showed no adverse cognitive effects.³⁰

What efforts are underway to improve treatment?

Researchers are looking for ways to better understand, diagnose and treat depression among all groups of people. New potential treatments are being tested that give hope to those who live with depression that is particularly difficult to treat, and researchers are studying the risk factors for depression and how it affects the brain. NIMH continues to fund cutting–edge research into this debilitating disorder.

For more information on NIMH-funded research on depression, visit the NIMH website.

How can I help a friend or relative who is depressed?

If you know someone who is depressed, it affects you too. The first and most important thing you can do to help a friend or relative who has depression is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with him or her to see the doctor. Encourage him or her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

To help a friend or relative:

• Offer emotional support, understanding, patience and encouragement.
• Engage your friend or relative in conversation, and listen carefully.
• Never disparage feelings your friend or relative expresses, but point out realities and offer hope.
• Never ignore comments about suicide, and report them to your friend's or relative's therapist or doctor.
• Invite your friend or relative out for walks, outings and other activities. Keep trying if he or she declines, but don't push him or her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure.
• Remind your friend or relative that with time and treatment, the depression will lift.

How can I help myself if I am depressed?

If you have depression, you may feel exhausted, helpless and hopeless. It may be extremely difficult to take any action to help yourself. But it is important to realize that these feelings are part of the depression and do not accurately reflect actual circumstances. As you begin to recognize your depression and begin treatment, negative thinking will fade.

To help yourself:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed. Participate in religious, social or other activities.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.

Mental Health Resources:

• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• Mental health programs at universities or medical schools
• State hospital outpatient clinics
• Family services, social agencies or clergy
• Peer support groups
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies
• You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor also can provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?

If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately.

• Call your doctor.
• Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
• Make sure you or the suicidal person is not left alone.

Citations

1. Altshuler LL, Hendrich V, Cohen LS. Course of mood and anxiety disorders during pregnancy and the postpartum period. Journal of Clinical Psychiatry, 1998; 59: 29.

2. Rohan KJ, Lindsey KT, Roecklein KA, Lacy TJ. Cognitive-behavioral therapy, light therapy and their combination in treating seasonal affective disorder. Journal of Affective Disorders, 2004; 80: 273-283.

3. Regier DA, Rae DS, Narrow WE, Kaebler CT, Schatzberg AF. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry, 1998; 173 (Suppl. 34): 24-28.

4. Devane CL, Chiao E, Franklin M, Kruep EJ. Anxiety disorders in the 21st century: status, challenges, opportunities, and comorbidity with depression. American Journal of Managed Care, 2005 Oct; 11(Suppl. 12): S344-353.

5. Shalev AY, Freedman S, Perry T, Brandes D, Sahar T, Orr SP, Pitman RK. Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry, 1998; 155(5): 630-637.

6. Conway KP, ComptonW, Stinson FS, Grant BF. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 2006 Feb; 67(2): 247-257.

7. Cassano P, Fava M. Depression and public health, an overview. Journal of Psychosomatic Research, 2002; 53: 849-857.

8. Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. Journal of Psychosomatic Research, 2002; 53: 859-863.

9. Tsuang MT, Faraone SV. The genetics of mood disorders. Baltimore, MD: Johns Hopkins University Press, 1990.

10. Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83.

11. Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: implications for affective regulation. Biological Psychiatry, 1998; 44(9): 839-850.

12. Pollack W. Mourning, melancholia and masculinity: recognizing and treating depression in men. In: Pollack W, Levant R, eds. New Psychotherapy for Men. New York: Wiley, 1998; 147-166.

13. Cochran SV, Rabinowitz FE. Men and Depression: clinical and empirical perspectives. San Diego: Academic Press, 2000.

14. Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004.

15. Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. American Family Physician, 1999; 60(3): 820-826.

16. Krishnan KRR, Taylor WD, et al. Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression. Biological Psychiatry, 2004; 55: 390-397.

17. Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide and Life Threatening Behavior, 2001; 31(Suppl.): 32-47.

18. Little JT, Reynolds CF III, Dew MA, Frank E, Begley AE, Miller MD, Cornes C, Mazumdar S, Perel JM, Kupfer DJ. How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? American Journal of Psychiatry, 1998; 155(8): 1035-1038.

19. Reynolds CF III, Frank E, Perel JM, Imber SD, Cornes C, Miller MD, Mazumdar S, Houck PR, Dew MA, Stack JA, Pollock BG, Kupfer DJ. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 1999; 281(1): 39-45.

20. Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life: consensus statement update. Journal of the American Medical Association, 1997; 278(14): 1186-1190.

21. Reynolds CF III, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, Houck PR, Mazumdar S, Butters MA, Stack JA, Schlernitzauer MA, Whyte EM, Gildengers A, Karp J, Lenze E, Szanto K, Bensasi S, Kupfer DJ. Maintenance treatment of major depression in old age. New England Journal of Medicine, 2006 Mar 16; 354(11): 1130-1138.

22. Weissman MM, Wolk S, Goldstein RB, Moreau D, Adams P, Greenwald S, Klier CM, Ryan ND, Dahl RE, Wichramaratne P. Depressed adolescents grown up. Journal of the American Medical Association, 1999; 281(18): 1701-1713.

23. Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry, 2000; 57: 21-27.

24. Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339-348.

25. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807-820.

26. Rush JA, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, Sertraline, or Venlafaxine-XR after failure of SSRIs for depression. New England Journal of Medicine, 2006 Mar 23; 354(12): 1231-1242.

27. Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush JA. Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine, 2006 Mar 23; 354(12): 1243-1252.

28. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. Journal of the American Medical Association, 2007; 297(15): 1683-1696.

29. Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. Journal of the American Medical Association, 2002; 287(14): 1807-1814.

30. Rami L, Bernardo M, Boget T, Ferrer J, Portella M, Gil-Verona JA, Salamero M. Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one-year longitudinal study. The Journal of Neuropsychiatry and Clinical Neurosciences, 2004; 16: 465-471.

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For More Information

Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order paper brochures through the mail. If you would like to have NIMH publications, you can order them online at www.nimh.nih.gov. If you do not have Internet access and wish to have information that supplements this publication, please contact the NIMH Information Center at the numbers listed below.

Please check the NIMH Web site for the most up-to-date information on this topic.

National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or
1-866-615-NIMH (6464) toll-free
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FAX: 301-443-4279
E-mail: [email protected]
Web site: http://www.nimh.nih.gov

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Source: U.S. Department of Health and Human Services
National Institutes of Health
NIH publication No. 08 3561
Revised 2008
Page last reviewed by NIMH: September 23, 2010

Reviewed by athealth.com February 3, 2014

What is depression?

Depression is a prolonged or deep emotional sensation of sadness, being "blue", or "down." Depressive feelings such as discouragement or sadness are perfectly normal if they do not become too severe or last too long. Depression becomes a clinical problem if a person's mood becomes too depressed or if the episode lasts more than two weeks. If there is any question about the severity of a person's depression, he/she should have an immediate evaluation by a mental health professional or a physician in order to rule out suicidal intent.

What characteristics are associated with depression?

Depression includes some of the following characteristics:

• Feeling sad, blue, or down
• Feeling unworthy
• Feeling guilty
• Feeling helpless
• Loss of energy
• Feeling restless
• Feeling irritable
• Feeling lethargic
• Fatigue
• Increased sleep or decreased sleep
• Insomnia or awakening during the night
• Awakening earlier or later than normal
• Loss of interest in hobbies, activities
• Loss of interest in sex
• Decreased ability to concentrate
• Decreased ability to remember
• Increase or decrease of appetite
• Increase or decrease in weight
• Thoughts of death
• Thoughts of suicide

Are there genetic factors associated with depression?

Depression tends to occur in families. If someone is depressed, it is at least twice as likely that a close relative has had or will have depression. Also, it is common to find such problems as substance abuse or ADHD in the close relatives of depressed people.

Does depression affect males, females, or both?

Anyone, male or female, can get depressed. However, in the United States, women become depressed about twice as often as men.

At what age does depression appear?

Depression can strike a person at any age. Even small children can become depressed if they experience a serious loss such as the death of a parent.

Depression is quite common in adolescence and adulthood. Also, it is not unusual to find depression in the geriatric population where loss is so evident.

How often is depression seen in our society?

Depression is very prevalent in our society. Today, more than 10 million Americans are being treated for depression.

How is depression diagnosed?

A mental health professional arrives at the diagnosis of depression by taking a careful, personal history from the client/patient. The personal history consists of the recent events associated with the depressed mood, a past history, and a family history. The client/patient may be asked to complete a mood inventory or depression questionnaire. There are no laboratory tests necessary to diagnose depression nor are there any physical conditions that must be met. However, it is very important not to overlook a physical illness that might mimic or contribute to depression. If there is any possibility that the client/patient may have a physical problem, the mental health professional should recommend a complete physical examination by a medical doctor. It is not uncommon for people with depression to have symptoms of physical illness. Many physicians make the diagnosis of depression while attempting to find the cause of a patient's headache, fatigue, sleep, or other physical problems.

Depression may follow a significant personal loss. For instance, the loss of a loved one, the loss of a job, or a move to a new location may trigger a depressed mood. Some depression is caused by a chemical imbalance in the brain. The chemical imbalances associated with depression resemble chemical imbalances in the body that are associated withother common diseases such as diabetes

How is depression treated?

Although some depression may go away on its own, people with depression can often be greatly helped with treatment. The treatment for depression consists of psychotherapy, medication, or both. A friend or family member who encourages the depressed person to seek professional help may be a lifesaver. Many people cannot lift themselves out of their depression alone. They need the care and empathy of friends and family, and many benefit from the help of a mental health professional.

Most depression is treated in an outpatient setting. However, seriously depressed people who have thoughts of suicide must be considered for immediate hospitalization. Suicidal thoughts should always be taken seriously. In 2007, suicide was the tenth leading cause of death in the U.S., accounting for 34,598 deaths¹, and it was the third leading cause of death for young people ages 15 to 24.¹

Many people with depression are relieved after their initial session of therapy. Knowing that someone understands and that there is a professional who can help is an enormous relief to many who suffer from depression. However, it generally takes at least a couple of weeks after beginning therapy before people begin to feel better.

The treatment of depression can sometimes be enhanced with the use of prescribed medications called anti-depressants. If medications are prescribed, it usually takes ten to fourteen (10 - 14) days before most people begin to appreciate the benefit of the antidepressants.

What happens to someone with depression?

The course of depression is quite variable. Some people will experience only one significant depressive episode for which they receive treatment, and they may never have another episode. Other people may have recurrent bouts of depression that require intermittent treatment throughout their lives. Still others suffer from chronic depression and have to remain in therapy and/or on medication for many years.

What can people do if they need help?

If you, a friend, or a family member would like more information about depression, you are encouraged to discuss your concerns with a physician or a mental health professional.

Centers for Disease Control and Prevention
National Center for Injury Prevention and Control
Web-based Injury Statistics Query and Reporting System (WISQARS)
http://www.cdc.gov/injury/wisqars/index.html

Page last modified or reviewed by athealth.com on February 3, 2014

Introduction

Depression can strike anyone. Depression not only affects your brain and behavior - it affects your entire body. Depression has been linked with other health problems, including diabetes. Dealing with more than one health problem at a time can be difficult, so proper treatment is important.

What is depression?

Major depressive disorder, or depression, is a serious mental illness. Depression interferes with your daily life and routine and reduces your quality of life. About 6.7 percent of U.S. adults ages 18 and older have depression.¹

What is diabetes?

Diabetes is an illness that affects the way the body uses digested food for energy. Most of the food we eat is broken down into a type of sugar called glucose. Glucose is an important source of fuel for the body and the main source of fuel for the brain. The body also produces a hormone called insulin. Insulin helps cells throughout the body absorb glucose and use it for energy. Diabetes reduces or destroys the body's ability to make or use insulin properly. Without insulin, glucose builds up in the blood, and the body's cells are starved of energy.

How are depression and diabetes linked?

Studies show that depression and diabetes may be linked, but scientists do not yet know whether depression increases the risk of diabetes or diabetes increases the risk of depression. Current research suggests that both cases are possible.

In addition to possibly increasing your risk for depression, diabetes may make symptoms of depression worse. The stress of managing diabetes every day and the effects of diabetes on the brain may contribute to depression.^2,3 In the United States, people with diabetes are twice as likely as the average person to have depression.⁴

At the same time, some symptoms of depression may reduce overall physical and mental health, not only increasing your risk for diabetes but making diabetes symptoms worse. For example, overeating may cause weight gain, a major risk factor for diabetes. Fatigue or feelings of worthlessness may cause you to ignore a special diet or medication plan needed to control your diabetes, worsening your diabetes symptoms. Studies have shown that people with diabetes and depression have more severe diabetes symptoms than people who have diabetes alone.⁴

How is depression treated in people who have diabetes?

Depression is diagnosed and treated by a health care provider. Treating depression can help you manage your diabetes and improve your overall health. Scientists report that for people who have diabetes and depression, treating depression can raise mood levels and increase blood glucose control.⁵ Recovery from depression takes time but treatments are effective.

At present, the most common treatments for depression include:

• Cognitive behavioral therapy (CBT), a type of psychotherapy, or talk therapy, that helps people change negative thinking styles and behaviors that may contribute to their depression
• Selective serotonin reuptake inhibitor (SSRI), a type of antidepressant medication that includes citalopram (Celexa), sertraline (Zoloft), and fluoxetine (Prozac)
• Serotonin and norepinephrine reuptake inhibitor (SNRI), a type of antidepressant medication similar to SSRI that includes venlafaxine (Effexor) and duloxetine (Cymbalta).

Some antidepressants may cause weight gain as a side effect and may not be the best depression treatment if you have diabetes. These include:

• Tricyclics
• Monoamine oxidase inhibitors (MAOIs)
• Paroxetine (Paxil), an SSRI6
• Mirtazapine (Remeron)

While currently available depression treatments are generally well tolerated and safe, talk with your health care provider about side effects, possible drug interactions, and other treatment options. For the latest information on medications, visit the U.S. Food and Drug Administration website. Not everyone responds to treatment the same way. Medications can take several weeks to work, may need to be combined with ongoing talk therapy, or may need to be changed or adjusted to minimize side effects and achieve the best results.

More information about depression treatments can be found on the NIMH website. If you think you are depressed or know someone who is, don't lose hope. Seek help for depression.

Citations

1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun; 62(6):617-27.

2. Golden SH, Lazo M, Carnethon M, Bertoni AG, Schreiner PJ, Roux AV, Lee HB, Lyketsos C. Examining a bidirectional association between depressive symptoms and diabetes. JAMA. 2008 Jun 18; 299(23):2751-9.

3. Kumar A, Gupta R, Thomas A, Ajilore O, Hellemann G. Focal subcortical biophysical abnormalities in patients diagnosed with type 2 diabetes and depression. Arch Gen Psychiatry. 2009 Mar; 66(3):324-30.

4. Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care. 2002 Mar; 25(3):464-70.

5. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun; 24(6):1069-78.

6. Antidepressants and weight gain: What causes it? July 23, 2010. http://www.mayoclinic.com/health/antidepressants-and-weight-gain/AN01396 Accessed on January 25, 2012.

National Institutes of Health
NIH Publication No. 11-5003
Revised 2011

Reviewed by athealth.com on February 3, 2014

For many years, depression and other disorders of mood were thought to be afflictions of only adults. Within the past three decades, however, it has become evident that mood disorders are common among children and adolescents. Population studies reveal that between 10% and 15% of the child and adolescent population exhibit some symptoms of depression (U. S. Department of Health and Human Services [USDHHS], 2000).

In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder. This digest focuses on these three disorders as they are exhibited in childhood and adolescence - their symptoms, causal factors, and treatment.

Major Depressive Disorder

Major depressive disorder is a serious condition characterized by one or more major depressive episodes. In children and adolescents, an episode lasts an average of seven to nine months (Birmaher et al., 1996a, 1996b). Depressed children are sad and lose interest in activities they used to enjoy. They feel unloved, pessimistic, or even hopeless; they think that life is not worth living; and they may think about or threaten suicide. They are often irritable, which may lead to disruptive or aggressive behavior. They may be indecisive, have problems concentrating, and lack energy or motivation. They may neglect appearance and hygiene, and their normal eating and sleeping patterns may be disturbed (USDHHS, 2000).

Dysthymic Disorder

Dysthymic disorder has fewer symptoms, but is more persistent. The child or adolescent is depressed for most of the day on most days, and symptoms may continue for several years, the average dysthymic period being approximately four years. Seventy percent of children and adolescents with dysthymia eventually experience an episode of major depression. When this combination of major depression and dysthymia occurs, the condition is referred to as double depression (USDHHS, 2000).

Bipolar Disorder

In bipolar disorder, episodes of depression alternate with episodes of mania. The depressive episode usually comes first, with the first manic features becoming evident months or even years later. Adolescents with mania feel energetic and confident; may have difficulty sleeping but do not tire; and talk a great deal, often speaking very loudly or rapidly. They may complain of racing thoughts. They may do schoolwork quickly and creatively, but in a chaotic, disorganized way. In the manic stage, they may have exaggerated or even delusional ideas about their capabilities and importance, become overconfident, and be uninhibited with others. They may engage in reckless behavior (e. g., fast driving or unsafe sex). Sexual preoccupations are increased and may be associated with promiscuous behavior (USDHHS, 2000).

Other Disabilities Associated With Depressive Disorders

Approximately two-thirds of children and adolescents with major depressive disorder also have another mental disorder, such as anxiety disorder, conduct disorder, oppositional defiant disorder, psychoactive substance abuse or dependence, or phobias (Anderson & McGee, 1994). Authorities have also noted that children with medical problems often face extreme and/or chronic stress, which places them at risk for depression. Estimates of depression among youngsters with medical problems range from 7% in general medical patients to 23% in orthopedic patients (Guetzloe, 1991). Depression has also been linked to a variety of other medical conditions, including endocrinopathies and metabolic disorders (e.g., diabetes and hypoglycemia), viral infections (e.g., influenza, viral hepatitis, and viral pneumonia), rheumatoid arthritis, cancer, central nervous system disorders, metal intoxications, and disabling diseases of all kinds. Some of these conditions may be temporary, but some may be diagnosed as primary disabilities in youngsters with health impairments.

The Link Between Depression and Suicide

A number of studies have confirmed that children and adolescents with depression are at high risk for suicidal behavior (see Guetzloe, 1991). Because mood disorders substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for parents, educators, and clinicians who deal with the mental health problems of children and adolescents. Over 90% of children and adolescents who commit suicide have a mental disorder (USDHHS, 2000).

Causal Factors Related to Depression

The precise causes of depression are not known. Research on adults with depression generally points to both biological and psychosocial factors, but there has been considerably less research on children and adolescents (Kendler, 1995).

• Family and genetic factors. Between 20% and 50% of depressed children and adolescents have a family history of depression. It is not clear whether the relationship between parent and childhood depression derives from genetic factors or if depressed parents create an environment in which children are more likely to develop mental disorders (USDHHS, 2000).
• Biological factors. Biochemical and physiological correlates of depression have been studied by medical researchers, with results that generally point to a chemical imbalance in the brain as a causal factor (Birmaher et al., 1996a,1996b). Most of these studies have been conducted with adults, so the findings may not apply to children and adolescents (Guetzloe, 1991).
• Cognitive factors. For several decades there has been considerable interest in the relationship between a pessimistic mindset and a predisposition to depression. Pessimistic individuals generally react more passively, helplessly, and ineffectively to negative events than optimistic individuals. The specific origins of pessimistic mindset have not been established (USDHHS, 2000) but are topics of current research interest (Alloy et al., 2001; Garber & Flynn, 2001).

Diagnosis and Assessment of Depressive Illness in Young People

Recent research has focused on the development and validation of checklists and protocols to be used by mental health professionals along with clinical interviews and medical tests. An accurate diagnosis of depression is a complex task, extremely difficult for even highly skilled physicians and other clinicians. It requires a careful examination of physical, mental, emotional, environmental, and cultural factors related to the child or adolescent, his/her family, and the environment. Teachers, counselors, and other school personnel are not expected to diagnose depression in young people; the major roles of educators are to detect the symptoms of depression and make appropriate referrals.

Treatment of Depressive Disorders

Treatment approaches for children and adolescents include psychosocial interventions (e. g., cognitive behavior therapy) and medication, as well as traditional psychotherapy. Two forms of cognitive therapy (i.e., self-control therapy for prepubertal children and coping skills for adolescents) have been judged as probably effective (Kaslow & Thompson, 1998). A number of medications are commonly prescribed for children and adolescents with depression, but many of these have not yet been subjected to sufficient study. Effective treatment requires intervention by both medical and mental health professionals, with support from all others who come in contact with the young person; and is therefore not within the purview of the school alone.

School and Classroom Intervention

The educator's most important contribution is the provision of a positive and supportive environment, components of which include satisfaction of basic needs, caring relationships with adults, and physical and psychological security. Any inclusion in a student's program that serves to enhance feelings of self-worth, self-control, and optimism has the potential for ameliorating feelings of depression. Aversive techniques (e. g., punishment and "get tough" approaches) should be avoided to the extent possible (Guetzloe, 1989, 1991).

Educators must use instructional strategies that are both positive and effective so that the student will achieve success and enjoy the learning process. Examples include direct instruction with positive reinforcement, thematic instructional units with varied levels of classroom assignments, learning strategies (e. g., mnemonic devices) and utilization of the principles of universal design for leaning, which promote access to the general curriculum for students with learning problems. Some protective factors have been addressed in published curricula (e. g., preventing alienation, enhancing self-esteem, and learning self-control). Other interventions that have implications for school programs (e. g., phototherapy and exercise) have been found to have value in reducing symptoms of depression in adults (Brosse, Sheets, Lett, & Blumenthal, 2002; USDHHS, 2003), but have not yet been subjected to sufficient study with children and adolescents.

Summary

Mood disorders, including major depression, dysthymia, and bipolar disorder, are now recognized as serious problems among children and adolescents. This brief discussion has focused on the symptoms of these disorders, their relationships to other mental and physical problems, their treatment, and appropriate school intervention.

Resources

Alloy, L.B., Abramson, L.Y., Tashman, N., Berrebbi, D.S., Hogan, M.E., Whitehouse, W.G., Crossfield, A.G., & Morocco, A. (2001). Developmental origins of cognitive vulnerability to depression: Parenting, cognitive, and inferential feedback styles of the parents of individuals at high and low cognitive risk for depression. Cognitive Therapy and Research, 25, 397-423.

Anderson, J. C., & & McGee, R. (1994). Comorbidity of depression in children and adolescents. In W. M. Reynolds & H. F. Johnson (Eds.), Handbook of depression in children and adolescents (pp. 581-601). New York: Plenum.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., & Kaufman, J. (1996a). Childhood and adolescent depression: A review of the past 10 years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1575-1583.

Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., Perel, J., & Nelson, B. (1996b). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1427-1439.

Brosse, A. L., Sheets, E. S., Lett, H. S., & Blumenthal, J. A. (2002). Exercise and the treatment of clinical depression in adults: Recent findings and future directions. Sports Medicine 32 (12),741-760.

Garber, A., & Flynn, C. A. (2001).Predictors of depressive cognitions in young adolescents. Cognitive Therapy and Research, 25, 353-376.

Guetzloe, E. C. (1991). Depression and suicide: Special education students at risk. Reston, VA: Council for Exceptional Children.

Guetzloe, E. C. (1989). Youth suicide: What the educator should know. Reston, VA: The Council for Exceptional Children.

Kaslow, N. J., & Thompson, M. P. (1998). Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child and adolescent depression. Journal of Clinical Child Psychology, 27, 146-155.

Kendler, K. S. (1995). Genetic epidemiology in psychiatry. Taking both genes and environment seriously. Archives of General Psychiatry, 52, 895-899.

U. S. Department of Health and Human Services (USDHHS). (2000). Mental health: A report of the Surgeon General. Rockville, MD: U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administraion, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U. S. Department of Health and Human Services (2003). Mood disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administraion, The Center for Mental Health Services, National Institutes of Health, National Institute of Mental. http://www.mentalhealth.org/publications/allpubs/ken98-0049/default.asp
Source: ERIC Digest
ERIC Clearinghouse on Disabilities and Gifted Education
ERIC Identifier: ED482340
Publication Date: 2003-08-00
Author: Eleanor Guetzloe

Reviewed by athealth.com February 3, 2014

Depression can strike anyone.

People with serious illnesses such as HIV may be at greater risk. Even when undergoing complicated treatment regimens for other illnesses, depression should always be treated.

Research has enabled many men and women, and young people living with HIV to lead fuller, more productive lives. As with other serious illnesses such as cancer, heart disease or stroke, however, HIV often can be accompanied by depression, an illness that can affect mind, mood, body and behavior. If left untreated, depression can increase the risk for suicide.

Although as many as one in three persons with HIV may suffer from depression, family and friends and even many primary care physicians often misinterpret depression's warning signs. They often mistake these symptoms for natural accompaniments to HIV in the same way that family members and doctors often erroneously assume that symptoms of depression are a natural accompaniment to growing old.

Depression can strike at any age. NIMH-sponsored studies estimate that six percent of 9- to 17-year olds, and seven percent of the entire U.S. adult population experience some form of depression every year—women at twice the rate of men. Although available therapies alleviate symptoms in over 80 percent of those treated, nearly two-thirds of those who suffer from depression don't get the help they need.

Treat your depression

Persons with depression and HIV must overcome stigma associated with both illnesses. Despite the enormous advances in brain research in the past 20 years, the stigma of mental illness remains. Even people who have access to good health care often fail or refuse to recognize their depression and seek treatment.

Depression is a disease that affects how a person relates to people around them, and if left untreated, can cause relationships to deteriorate. Some people respond to depression by becoming angry and abusive to people who care about them, or children who depend on them. Many choose to treat their depression themselves with alcohol or street drugs, which can quicken HIV's progression to AIDS. Others turn to herbal remedies. Recently scientists have discovered that St. John's wort, an herbal remedy sold over-the-counter to treat mild depression, reduces blood levels of the protease inhibitor indinavir (Crixivan®) and probably the other protease inhibitors as well. If taken together, the combination could allow the AIDS virus to rebound, perhaps in a drug-resistant form. (See the alert on the NIMH website: http://www.nimh.nih.gov/events/stjohnwort.cfm).

Prescription antidepressant medications are generally well tolerated and safe for people with HIV. There are, however, interactions among some of the drugs that require careful monitoring.

So, if you or someone you know with HIV is exhibiting the pattern of depressive symptoms described below, seek out the services of a health care provider. And make certain that he or she is experienced in diagnosing and treating depression in people with HIV.

Some of the symptoms of depression could be related to HIV, specific HIV-related disorders, or medication side effects. They could just be a normal part of living. Everyone has bad days.

Clinical depression is different from normal ups and downs

• The symptoms last all day every day for at least two weeks
• The symptoms occur together during the same time period
• The symptoms cause daily events such as work, self-care and child care or social activities to be extremely difficult or impossible.

Taking the above characteristics into account, examine the symptoms listed below and see if they characterize you or someone you know living with HIV:

• Feelings of sadness, hopelessness
• Loss of interest in formerly enjoyable activities, including sex
• A sense that life is not worth living or that there is nothing to look forward to
• Feelings of excessive guilt, or a feeling that one is a worthless person
• Slowed or agitated movements (not in response to discomfort)
• Recurrent thoughts of dying or of ending one's own life, with or without a specific plan
• Significant, unintentional weight loss and decrease in appetite; or, less commonly, weight gain and increase in appetite
• Insomnia or excessive sleeping
• Fatigue and loss of energy
• A diminished ability to think, concentrate, or make decisions
• Physical symptoms of anxiety, including dry mouth, cramps, diarrhea, and sweating

Many therapies are available, but they must be carefully chosen by a trained professional, based on the particular circumstances of the patient and family. Recovery from depression takes time. Medications for depression can take several weeks to begin to work and may need to be combined with on-going psychotherapy. Not everyone responds to the medications in the same way. Dosing may need to be adjusted. Prescriptions may need to be changed.

Other mood disorders besides depression, such as various forms of manic-depression, also called bipolar disorder, may occur with HIV. Bipolar disorder is characterized by mood swings, from depression to mania.

Mania

Mania is characterized by abnormally and persistently elevated (high) mood or irritability accompanied by at least three of the following symptoms:

• Overly-inflated self-esteem
• Decreased need for sleep
• Increased talkativeness
• Racing thoughts
• Distractibility
• Increase in goal-directed activity such as shopping
• Physical agitation
• Excessive involvement in risky behaviors or activities

Click here for more information on bipolar disorder.

People with HIV also have a high incidence of anxiety disorders such as panic disorder. For free brochures on anxiety disorders and their treatment, phone 1-88-88-ANXIETY (1-888-826-9438) or use the online order form.

It takes more than access to good medical care for persons living with HIV to stay healthy. A positive outlook, determination and discipline are also required to deal with the extra stress: avoiding high-risk behaviors, keeping up with the latest scientific advances, adhering to complicated medication regimens, reshuffling schedules for doctor visits, and grieving over the death of loved ones.

The causes of depression are still not clear. It may result from an underlying genetic predisposition triggered by stress, or by the side effects of medications, or by viruses like HIV that can affect the brain. Whatever its origins, depression can sap the energy needed to keep focused on staying healthy, and research shows that it can accelerate HIV's progression to AIDS.

Remember, depression is a treatable disorder of the brain

Depression can be treated in addition to whatever other illnesses a person might have, including HIV. If you or someone you know with HIV is depressed, seek help from a health care professional who is experienced in treating persons with both diseases. Don't lose hope.

For more information on NIMH's activities and programs in HIV and AIDS research contact:

Center for Mental Health Research on AIDS
Division of Mental Disorders
Behavioral Research and AIDS
National Institute of Mental Health
http://www.nimh.nih.gov/health/publications/depression-and-aids/index.shtml
July 2000

Reviewed by athealth.com on February 3, 2014

Answers to students' frequently asked questions about depression.

Depression can occur during adolescence, a time of great personal change. You may be facing changes in where you go to school, your friends, your after-school activities, as well as in relationships with your family members. You may have different feelings about the type of person you want to be, your future plans, and may be making decisions for the first time in your life.
Many students don't know where to go for mental health treatment or believe that treatment won't help. Others don't get help because they think depression symptoms are just part of the typical stresses of school or being a teen. Some students worry what other people will think if they seek mental health care.

This fact sheet addresses common questions about depression and how it can affect high school students.

Q. What is depression?

A. Depression is a common but serious mental illness typically marked by sad or anxious feelings. Most students occasionally feel sad or anxious, but these emotions usually pass quickly - within a couple of days. Untreated depression lasts for a long time and interferes with your day-to-day activities.

Q. What are the symptoms of depression?

A. Different people experience different symptoms of depression. If you are depressed, you may feel:

• Sad
• Anxious
• Empty
• Hopeless
• Guilty
• Worthless
• Helpless
• Irritable
• Restless.

You may also experience one or more of the following symptoms:

• Loss of interest in activities you used to enjoy
• Lack of energy
• Problems concentrating, remembering information, or making decisions
• Problems falling sleep, staying asleep, or sleeping too much
• Loss of appetite or eating too much
• Thoughts of suicide or suicide attempts
• Aches, pains, headaches, cramps, or digestive problems that do not go away.

Depression in adolescence frequently co-occurs with other disorders such as anxiety, disruptive behavior, eating disorders or substance abuse. It can also lead to increased risk for suicide.

Q. Are there different types of depression?

A. Yes. The most common depressive disorders are:

• Major depressive disorder, also called major depression. The symptoms of major depression are disabling and interfere with everyday activities such as studying, eating, and sleeping. People with this disorder may have only one episode of major depression in their lifetimes. But more often, depression comes back repeatedly.

• Dysthymic disorder, also called dysthymia. Dysthymia is mild, chronic depression. The symptoms of dysthymia last for a long time - two years or more. Dysthymia is less severe than major depression, but it can still interfere with everyday activities. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

 

Other types of depression include:

• Psychotic depression - severe depression accompanied by some form of psychosis, such as hallucinations and delusions

• Seasonal affective disorder - depression that begins during the winter months and lifts during spring and summer.

 

Q. What causes depression?

A. Depression does not have a single cause. Several factors can lead to depression. Some people carry genes that increase their risk of depression. But not all people with depression have these genes, and not all people with these genes have depression. Environment - your surroundings and life experiences - also affects your risk for depression. Any stressful situation may trigger depression. And high school students encounter a number of stressful situations!

Q. How can I find out if I have depression?

A. The first step is to talk with your parents or a trusted adult who can help you make an appointment to speak with a doctor or mental health care provider. Some school counselors may also be able to help you find appropriate care.

The doctor or mental health care provider can do an exam to help determine if you have depression or if you have another health or mental health problem. Some medical conditions or medications can produce symptoms similar to depression.

The doctor or mental health care provider will ask you about:

• Your symptoms
• Your history of depression
• Your family's history of depression
• Your medical history
• Alcohol or drug use
• Any thoughts of death or suicide.

Q. How is depression treated?

A. A number of very effective treatments for depression are available. The most common treatments are antidepressants and psychotherapy. An NIMH-funded clinical trial of 439 teens with major depression found that a combination of medication and psychotherapy was the most effective treatment option.¹ A doctor or mental health care provider can help you find the treatment that's right for you.

Q. What are antidepressants?

A. Antidepressants work on brain chemicals called neurotransmitters, especially serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways that they work.

Q. If a doctor prescribes an antidepressant, how long will I have to take it?

A. You will need to take regular doses of antidepressants for four to six weeks before you feel the full effect of these medicines. Some people need to take antidepressants for a short time. If your depression is long lasting or comes back again and again, you may need to take antidepressants longer.

Q. What is psychotherapy?

A. Psychotherapy involves talking with a mental health care professional to treat a mental illness. Types of psychotherapy often used to treat depression include:

• Cognitive-behavioral therapy (CBT), which helps people change negative styles of thinking and behavior that may contribute to depression

• Interpersonal therapy (IPT), which helps people understand and work through troubled personal relationships that may cause or worsen depression.

 

Depending on the type and severity of your depression, a mental health professional may recommend short-term therapy, lasting 10 to 20 weeks, or longer-term therapy.

Q. How can I help myself if I am depressed?

A. If you have depression, you may feel exhausted, helpless, and hopeless. But it is important to realize that these feelings are part of the depression and do not reflect your real circumstances. Treatment can help you feel better.

To help yourself feel better:

• Engage in mild physical activity or exercise
• Participate in activities that you used to enjoy
• Break up large projects into smaller tasks and do what you can
• Spend time with or call your friends and family
• Expect your mood to improve gradually with treatment
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Q. How can I help a friend who is depressed?

A. If you think a friend may have depression, you can help him or her get diagnosed and treated. Make sure he or she talks to an adult and gets evaluated by a doctor or mental health provider. If your friend seems unable or unwilling to seek help, offer to go with him or her and tell your friend that his or her health and safety is important to you.

Encourage your friend to stay in treatment or seek a different treatment if he or she does not begin to feel better after six to eight weeks.

You can also:

• Offer emotional support, understanding, patience, and encouragement
• Talk to your friend, not necessarily about depression, and listen carefully
• Never discount the feelings your friend expresses, but point out realities and offer hope
• Never ignore comments about suicide
• Report comments about suicide to your friend's parents, therapist or doctor
• Invite your friend out for walks, outings, and other activities - keep trying if your friend declines, but don't push him or her to take on too much too soon
• Remind your friend that with time and treatment, the depression will lift.

Q. What if I or someone I know is in crisis?

A. If you are thinking about harming yourself or having thoughts of suicide, or if you know someone who is, seek help right away.

• Call your doctor or mental health care provider.
• Call 911 or go to a hospital emergency room to get immediate help, or ask a friend or family member to help you do these things.
• Call your campus suicide or crisis hotline.
• Call the National Suicide Prevention Lifeline's toll-free, 24-hour hotline at 1-800-273-TALK (1-800-273-8255) or TTY: 1-800-799-4TTY (1-800-799-4889) to talk to a trained counselor.
• If you are in crisis, make sure you are not left alone.
• If someone else is in crisis, make sure he or she is not left alone.

Q. What efforts are underway to help high school students who have depression?

A. Researchers are studying new ways to diagnose and treat depression in high school age students. Increasing the early detection and treatment of depression can help more students succeed academically and achieve their goals in school and after graduation.

The National Institute of Mental Health (NIMH) sponsors research on the causes, diagnosis, and treatment of depression, including studies focused on adolescents and young adults.

References

¹ March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807-820.

Source: U.S. Department of Health and Human Services
National Institutes of Health

National Institute of Mental Health 2011

Reviewed by athealth.com on February 3, 2014