Although it’s one of the most common problems seen in office practice, patients rarely come to the doctor complaining of depression. They have fatigue, aching, insomnia, irritability, or “nerves.” But depression can cause severe disability. Treatment is suprisingly straightforward.

Depression is one of the most frequent problems we see in the office. It is an intriguing issue in part because it is so full of contradictions:

Patients with depression rarely talk about how sad they feel. They mistakenly think of depression as some sort of personal or moral failure that they should be able to “snap out of” on their own. But it’s almost impossible just to decide to feel happy. This is not a failure of will.

For many people, depression is a physical illness. It’s often inherited. Occasionally, someone may have a medical illness that itself causes depression (e.g., alcohol or drug abuse, thyroid disease, a stroke or heart attack, chronic pain, certain kinds of rheumatism or pancreatic problems, etc.).

Yet depression affects you psychologically. Sometimes, psychological causes are an important part of the illness, particularly if you ever were physically, emotionally, or sexually abused or suffered a severe shock.

Hopelessness and feeling that no one could do anything that could possibly help are part and parcel of this illness. Yet depression is often surprisingly easy to treat. And even when treatment helps people feel and function better, one of the most difficult problems is to get them to continue treatment.

Here are some of the facts about this surprisingly disabling illness:

    1. Most patients with depression feel as if they are ill or run down. This fatigue is often so severe they mistakenly believe they have some other illness. So, if you’re depressed, you may believe that you have a vitamin deficiency, “tired blood,” hypoglycemia, Lyme Disease, Epstein-Barr Syndrome or Chronic Fatigue Syndrome, PMS (premenstrual syndrome), thyroid or other gland problems, or “all run down and need rest.”
    1. You may have trouble concentrating. You won’t be able to pay attention to things like TV programs, books or magazine articles, your work, etc.
    1. You may have trouble sleeping or you may sleep too much. The most common sleep pattern is that you fall asleep OK and then wake up in the middle of the night for no reason. Then you can’t fall back asleep again easily, and you’re tired all day the next day.
    1. You may lose weight because of loss of appetite, or you may eat when upset and gain weight.
    1. You may lose the ability to enjoy yourself; having fun is just too much trouble. And your interest and ability to respond sexually may just disappear.
    1. You may become irritable and hard to live with. Depressed patients frequently tell us their families or co-workers complain how crabby they are. The patient has no idea why they’re so quick to get angry and snap back. Sometimes a marriage becomes threatened just because one spouse is depressed.
    1. You may have a variety of aches and pains. This is such a common problem that many depressed patients complain primarily of physical symptoms such as headache, muscle aches in the neck and back, an upset stomach, gas, or constipation. As a rule most of these symptoms go away when your depression responds to treatment.
    1. You may feel sad or blah or blue or down much of the time for no reason. This sad mood becomes the strongest when you are relaxing and have nothing much to do; it often goes away at work or when you are busy. It may be worst first thing in the morning and get better as the day progresses. You may cry for no reason every day or several days a week.
  1. You may feel guilty or bad or upset with yourself for no reason. You may like yourself very little, feel that you are not a worthy person or are the worst person on the face of the earth. If you also feel hopeless (a very common experience), you may feel there is nothing to live for and contemplate taking your own life. Warning: depression can be a fatal illness if not treated.

Depression is not your fault! It is caused in most people by an imbalance of brain chemicals and may be inherited. So it can be a physical illness.

Some people feel mildly depressed much of their lives. Others have episodes of depression now and then, sometimes during periods of stress and sometimes for no reason. Still others become depressed after a particularly upsetting event, such as a divorce or death of a spouse. Finally, certain medications can cause depression.

If these symptoms fit your current situation, here are some thoughts about what to do next. First, if you drink heavily or daily, or if you use cocaine or other drugs, tell your doctor. Your depression is a direct toxic effect of your drinking or drug use. Nearly half of all suicides are in individuals who drink or do drugs! The usual antidepressant treatments don’t work nearly so well in this situation until you’ve been clean and sober for a few weeks — and then often your depression goes away by itself.

Second, it is important to discuss this illness over with your spouse or other family members. Show them this handout and discuss it with them. Be sure your family understands that depression is not your fault and no amount of “will power” will help. You need treatment.

How do you treat depression?

Depression can be successfully treated most of the time. Treatment consists of antidepressant medications, psychotherapy, or both, depending upon your situation. Often a combination of approaches works best.

Patients frequently assume that antidepressant medication is habit-forming or some sort of upper or downer, a tranquilizer or a “mood pill.” Or it makes you “hooked” on it. As you’ll discover, this medication is actually quite different from that. Its purpose is simply to help you to feel normal: not high, not low, not happy, not sad, just normal. So if you’ve been going through life with a black cloud hanging over your head, the cloud goes away, and you feel normal again. Same you, same life, same problems. The way we know the medication is working is when you feel better and function better, too. You’re better able to deal with your problems, and with just getting though life in general.

One reason why the medication is so safe is that it can’t cover up your problems. If it doesn’t work, nothing happens. In fact, the biggest problem with antidepressant medications is people quit taking them as soon as they start feeling better. Then the depression comes back.

How can you tell when your antidepressant medication is working? When you say to yourself every morning, “I feel terrific! Why do I need this junk!” (And of course, if you stop, in a few weeks you feel bad again.)

You can also treat mild or moderate chronic depression without drugs. A special kind of psychotherapy called cognitive behavioral therapy (CBT) has been proven to relieve depression. Once you learn CBT, depression is often gone for good. It turns out that when your mood starts to dip, you initiate a series of “automatic thoughts” that drag you ever deeper into sadness. This process is automatic, and people don’t realizing it’s occurring.

So rather than talking about your problems, CBT shows you how your thoughts make you depressed, and how to change what you think. It requires a specially trained therapist. Doctors are beginning to recommend CBT as first-line treatment for depression. It often works as well as medication, and the effects last for years.

So not everyone requires medication. and for many others, nondrug treatments are an important adjunct to other therapy. Exercise is probably number one on the list: walk two miles a day as fast as you can (if you’re fit, in half an hour or less). It may take a while before you can go this far this quickly. Second, avoid junk food, particularly sugar and fatty foods. Finally, it seems obvious that vitamins would be helpful, but they are ineffective.