"Sadness is an emotion, whereas depression is an illness," says internist and geriatric psychiatrist Ken Robbins of the University of Wisconsin-Madison.
True clinical depression differs from the blues in two key ways:
- Severity: Symptoms are difficult enough to deal with that they interfere with everyday life.
- Duration: Symptoms are present nearly all the time and last for more than two weeks.
The following 11 warning signs indicate that a person isn't dealing with normal, transient emotions but with the illness of depression. Note that symptoms vary by individual: A depressed person isn't likely to have all 11 symptoms at once, and their severity may shift. Depression can be mild or major; either way, if several symptoms are present and last for more than two weeks, you or someone you’re concerned about may need medical help.
1. Persistent sad, anxious, or "empty" feelings
This symptom looks like a low mood but persists even after time goes by and the cause of the bad mood has cleared up or receded.
What to look for: Blank stares, loss of interest in life, an inability to feel or express happiness or other emotions. Or the person may report just feeling "empty" or "numb."
What else to know: Often the depressed person isn't fully aware of this symptom. Try asking, "When’s the last time you were happy?"
2. Feelings of hopelessness, worthlessness, or helplessness
In an "Eeyore-like" pessimistic way, the depressed person can't help feeling that everything is wrong and it's his or her fault (rather than the fault of the situation or the illness itself). It's a hallmark sign of major depression. In mild depression, the feelings are similar but less extreme.
How to tell: The person seems unable to see any positive flip side to things or light at the end of the tunnel -- and feels little sense of control over choices or events. The person talks and acts as if he or she has no options, can't see a different path, is useless and meaningless. He or she may fixate on past mistakes, ruminating over them and expressing guilt and self blame.
What else to know: Listen for comments like these: "It's hopeless." "I can't do anything about it." "I have no choice." "Nobody cares." "I'm stuck." "I should have/could have/ if only…."
3. Frequent crying episodes
The crying may not seem to have a direct or obvious trigger; sobs often come "out of nowhere." But it's not normal to cry every day (though the depressed person may not realize this).
What to look for: In between episodes you witness, you may notice red eyes, sniffles, cracking voice, balled-up tissues, and other trails to tears.
What else to know: Not every depressed person cries; in fact, some never do. Research has shown that women are more inclined to this behavior than men. A 2001 University of San Francisco study found that crying isn't related to the severity of depression and that people who cry more may have briefer depressive episodes.
4. Increased agitation and restlessness
Some people with depression fall on the "hyper" end of a spectrum of behaviors, where others are the opposite (see symptom #5).
What to look for: The person may seem unable to relax, more irritable than usual, quicker to anger, full of restless energy, seldom calm. Look for pacing, lashing out at others, frequent standing up and sitting back down.
What else to know: For the depressed person, everything seems magnified. So small slights or irritations aren't just pebbles in the psyche, they're giant boulders that get in the way of ordinary life.
5. Fatigue and decreased energy
Typically depressed people who don't show a lot of agitation and restlessness (symptom #4) experience the flip side of those behaviors -- an increased sluggishness and slowness.
What to look for: The person may complain of having no energy, of feeling unproductive, or of "slowing down." He or she may have quit exercising, seem tired a lot, move more slowly, and have slowed reactions. "To-Do" lists never get finished the way they once did. The person may skip work.
What else to know: Fatigue is a real mind-body problem. Low mood and loss of motivation are partly at work, as well as a physiological depletion of energy -- and the two forces keep reinforcing each other.
6. Loss of interest in activities or hobbies that were once pleasurable
This is one of the single most telling symptoms of depression.
What to look for: The person no longer takes pleasure in things that once brought enjoyment, whether the lives of children or grandchildren, a hobby or craft, exercise, cooking, book club, watching sports -- or anything. The person may begin to decline invitations, refuse to go out, not want to see friends or family.
What else to know: Some depressed people lose interest in sex. For others, sex functions as a kind of escape, used the same way some depressed people turn to alcohol or drugs.
7. Difficulty concentrating, remembering details, and making decisions
"Fuzzy thinking" is often apparent both to the depressed person and his or her family, friends, and colleagues.
How to tell: Various mental slips may become obvious, such as forgetting appointments and errands, making checkbook errors, misplacing objects, forgetting names, avoiding making plans, postponing decisions or deferring them to others. The person may begin writing reminders to himself or herself or take a long time reading (because it's harder to focus) It may become harder to perform complicated tasks.
What else to know: Cognitive changes associated with depression can look like dementia; in fact, people with dementia are prone to depression, and vice-versa.
8. Sleeping too much or not enough
Disordered sleep and depression are closely related; in some people, depression manifests as insomnia (inability to fall sleep or to stay asleep), while others experience the opposite extreme: All the person feels like doing is sleeping.
What to look for: Regular sleep routines are disrupted; staying up too late or going to bed unusually early; being unable to awaken on time; complaining about a poor night's sleep; sleeping long hours but fitfully -- so the person never feels rested; excessive napping by day.
What else to know: Depression is a leading cause of sleep problems, in part because it interferes with natural biological rhythms.
9. Poor appetite or overeating
Again, the symptom tends to show up as one extreme or the other: The person loses interest in eating or falls into a pattern of constant, emotionally triggered eating.
What to look for: Missed meals, picking at food (especially if this is a change for the person), lying about food intake; loss of interest even in formerly favorite foods, mindless munching and other mindless eating, throwing up after eating; weight gain or weight loss.
What else to know: Depression is a common cause of the eating disorders anorexia, bulimia, and binge eating. It's true both that depression can lead to eating disorders and that people with eating disorders can develop depression.
10. Expressing thoughts of dying or suicide
Depression is one of the conditions most commonly associated with suicide. It begins to seem like a logical way to end the pain and suffering. As many as 90 percent of those who commit suicide are clinically depressed, have a substance abuse problem, or both, according to the National Institutes of Mental Health. (Many people with depression self-medicate with alcohol, which lowers inhibitions and increases the risk for suicide.)
What to look for: The intention may be expressed directly, such as, "I wish I were dead" or "I want to kill myself," or "I want to end it all." Or the threats may be indirect: "You'd be better off without me." "I can't go on." "I wish it were over." "Soon I won't be around any more." Also beware of a preoccupation with death or evidence of plans to follow-through, like buying a gun, hoarding pills, giving away money, or suddenly changing a will.
What else to know: If you think someone you love may be suicidal, don't leave him or her alone. Rather than leaping right to asking, "Are you thinking about suicide?" Robbins says, ask a series of questions that build on one another to assess the person’s state of mind: How are you feeling? Are you feeling depressed? Are you feeling hopeless? Are you wondering if life is worth living? Are you considering suicide? Have you made a plan? Encouraging the person to talk about the intended suicide actually lowers (but doesn't remove) the risk of following through. Keep the person safe until he or she can be brought to a doctor or therapist. Or call 911 or a suicide hotline (the National Suicide Prevention Lifeline is USA(800) 273-8255).
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11. Persistent aches or pains, headaches, cramps, or digestive problems that don't ease with treatment
Depression is stressful. The physical effects of chronic stress, added to poor self-care brought on by changes in energy levels, sleep, and appetite, can cause an array of health problems.
What to look for: Increased self-medication (through pain relievers, alcohol, or abuse of prescription meds), increased complaints that don't seem to fit any kind of pattern, increased doctor visits (or refusal to see a doctor despite obvious complaints).
What else to know: Obviously any of these physical signs can be clues to health problems that are unrelated to depression. The point is to notice if these behaviors are clustering with other symptoms of depression -- and to get them addressed by a health professional so that they become one (or two, or three, or five) fewer bothersome aspects of the depressed person's life.
Silver lining: Getting a loved one to a doctor on the pretext of evaluating chronic symptoms allows you to also report the worrisome depressive symptoms, and get them checked out and, if necessary, treated. This is valuable, given that so many people with depression are in denial. After all, the majority of cases of depression, even the most severe, respond to treatment, according to the National Institute of Mental Health.
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