"Snap out of it!" "Get a grip!" "Just pull yourself together." "What's wrong with you?" "You just need to pray more." "You need to get out of yourself and give back to others." Some well-intentioned people have said things like these to individuals with depression. Rather than helping however, these foolish bits of advice hurt. Words spoken without proper understanding of clinical depression have made depressed people feel worse. Before giving advice it only makes sense to obtain some knowledge of the situation before you speak and say something hurtful.

The word "depression" can have different meanings to different people: to a landscaper, "depression" could be a sunken area of the ground. To an economist, "depression" will mean a down-turn for the economy. To a Toronto Maple Leafs fan, "depressed" is the feeling which accompanies a losing season. To a clinically depressed individual however, "depression" may feel like a never-ending state of hopelessness.

There is a huge difference between "feeling down" or "feeling sad" because of a particular situation and the downward spiral of hopelessness that can set in with "depression". The Centre for Addiction and Mental Health (CAMH) mentions on their website (www.camh.ca) that one misconception about depression is "people should just get over the blues and get on with their lives." CAMH goes on to say, "Clinical depression is not just unhappiness - it is a complex mood disorder caused by a variety of factors, including genetic predisposition, personality, stress and brain chemistry. While it can suddenly go into remission, depression is not something that people can 'get over' by their own effort."

Depression is a medical condition characterized by long-lasting feelings of intense sadness and hopelessness accompanied by additional mental and physical changes. Statistics show that approximately 1 in 10 men and 1 in 5 women will suffer from depression at some point in their lives. Depression is more common in adults than in children or in teenagers. Close to one and a half million Canadians have serious depression at any given moment, but what is disturbing is that less than 33% of these people seek any medical help. This means that there are a million or so Canadians with depression right now who are not trying to get medical help at all.

Types of Depression:

1. Clinical Depression (or Major Depressive Disorder)
Clinical depression is much more than simple unhappiness. Clinical depression (which is sometimes known as major depression) is the most serious type of depression in terms of the number and severity of symptoms. There can be significant individual differences in the symptoms and their severity. Suicidal thoughts may or may not be part of the symptoms, but usually the person affected with clinical depression may lose interest in regular daily activities, pleasure may disappear from doing these activities, sleeping and eating patterns may be altered, and energy levels may decrease. See the section on "Symptoms" below.

2. Dysthymia
This refers to a prolonged low to moderate level of depression usually persisting for at least 2 years. The symptoms are not as severe as in clinical depression, but dysthymia can have a major impact on a person's quality of life. Some people with dysthymia can develop major depression (clinical depression).

3. Bipolar Disorder (or Manic Depression)
About 1% of the population is affected by Bipolar Disorder and people in this group will experience emotional swings alternating from extreme "highs" to extreme "lows". These episodes may have nothing to do with particular events in someone's life; they can spontaneously occur independent of any trigger. Men and women are affected equally.

4. Seasonal Affective Disorder (S.A.D.)
S.A.D. is a subtype of depression that regularly occurs at the same time of year. In North America this usually happens in the fall or winter months.

5. Depression with Psychosis
This occurs with severe depression when it is associated with hallucinations (seeing or hearing things that are not real) or delusions (thoughts that are not based in reality).

6. Postpartum Depression
This is a subtype of depression that begins a few weeks after giving birth. Postpartum depression is different from "baby blues" which can occur 24 to 72 hours after a woman gives birth. "Baby blues" is a temporary state caused by hormonal changes associated with pregnancy and giving birth and usually resolves within about a week. Postpartum depression lasts longer and interferes with the mom's emotional and social functioning.


A combination of factors can make a person more susceptible to depression:
- physical illness
- stress
- certain medications
- biochemical imbalances in the brain, hormones, or immune system
- a predisposition to a negative view of life
- family history
It is not fully known what causes Bipolar Disorder, but since it tends to run in families research indicates that a genetic predisposition may contribute to this condition. Some research indicates that abnormalities in the way that some nerve cells in the brain function may be a cause. Factors that may contribute to the development of Bipolar Disorder can include stress, lack of sleep, upsetting life situations, as well as substance abuse of alcohol or drugs.

Symptoms of Depression:

Although we can all feel sad from time to time, clinical (major) depression is diagnosed when a patient has at least five of the following symptoms (one of which must be depressed mood or loss of interest or pleasure in daily activities) on most days for at least a 2 week period:
- depressed mood (sadness)
- loss of interest or loss of pleasure in daily activities, including sex
- fatigue
- trouble sleeping (insomnia) or chronic over-sleeping
- changes in activity level
- feelings of guilt or worthlessness
- difficulty in making decisions or in concentrating
- recurring thoughts of death or suicide (in the US, a person dies by suicide every 15 minutes, and there is an attempt every 40 seconds).

Other symptoms of depression may include:
- loss of interest in work
- avoiding friends and family
- irritability
- crying easily
- hallucinations (seeing or hearing things that are not real)
- delusions (having thoughts not based on reality)
- body aches and pain


Mental illness responds best to early identification and early treatment. Depression especially responds very well to treatment. Both depression and bipolar disorder can be treated with psychotherapy, counseling, education and medication. For patients who do not respond to any of these treatments, electroconvulsive therapy (ECT) may be of benefit.
Some of the more commonly used medications for depression are:
1. SSRI's (selective serotonin reuptake inhibitors) such as fluoxetine, paroxetine, citalopram and escitalopram. For patients who are taking citalopram, check with your doctor or pharmacist regarding a Health Canada Advisory (Jan.30, 2012) or visit www.hc-sc.gc.ca
2. SNRI's (serotonin-norepinephrine reuptake inhibitors) such as duloxetine, venlafaxine and desvenlafaxine.
3. Bupropion
4. Trazodone
5. Mirtazapine
6. MAOI's (monoamine oxidase inhibitors) like moclobemide
7. Tricyclic antidepressants such as amitriptyline, doxepin and nortriptyline.
Bipolar Disorder is often treated with mood stabilizers like lithium, divalproex, valproic acid or carbamazepine. The depression part of bipolar can be treated with antidepressants although they must be used with caution (and usually with a mood stabilizer). The symptoms of mania can be managed with antipsychotics such as olanzapine, risperidone or quetiapine.
If you have any questions regarding any of these medications that are used for treating depression or bipolar disorder, please ask your pharmacist.

Self-help groups are especially helpful in getting and staying on the road to recovery.
The Canadian Mental Health Association says, "a supportive network of family and friends is also very helpful. A depressed individual may not want the company of others, or conversely continuously wants the company of certain people. If you are a friend or family member, try to be patient and non-judgmental; listen rather than talk, and keep an open mind to their thoughts and feelings."


Healthy lifestyles can minimize the impact of mood disorders. Healthy lifestyles include good nutrition, physical activity, and maintaining a balance between work and play. Family, friends, social networks and community can help maintain mental well-being. Minimizing caffeinated beverages (which could increase anxiety) and minimizing alcohol (which is a depressant) are good prevention strategies.

There is hope:

Another misconception that people diagnosed with depression may believe is, "My life will never be normal again." CAMH states, "most people can and do return to function at the level they did before they became depressed."
The Canadian Mental Health Association says, "Don't let the stigma of mental illness - yours or that of others - prevent you from getting the help that is required. You would not hesitate to go to your doctor for a broken leg; seeking help for depression is no different. If you or someone you know is showing signs of depression or bipolar disorder, talk with your family doctor." For more information see the post from August, “Mental Health Issues.. Stigma”.

The Canadian Mental Health Association, Ontario, along with Mood Disorders of Canada, the Nutrition Resource Centre, York University and Trillium Ontario have a website devoted to the topic of prevention of mood disorders. For more information go to www.mindingourbodies.ca
"Mental Health Helpline" ( 1-866-531-2600 ) is a free and confidential health information service available 24 hours a day, 7 days a week. This is a live answer service funded by the Ontario government, a service of "ConnexOntario". Anyone may also e-mail questions to this service. See www.mentalhealthhelpline.ca/Home/Email
For types of mental health services available in Ontario as well as a list of "helpful links" for mental health issues, see www.connexontario.ca


Philip A. Smith, B.Sc.Phm.