Friends & Family: Understanding Depression

If one of your friends or a family member has depression, it can be a real struggle. Mental illness doesn't just affect the person with the illness, but everyone around them too. If you've never been there yourself, you will never completely get it. But there are some things I can tell you which may help you understand a little better, and some advice on how you can help.

Depression is neurological. When a person suffers from depression, their overall brain activity is significantly reduced, and this accounts for a lot of the symptoms which outsiders can find frustrating or confusing. So concentrating, paying attention, keeping up with a conversation, remembering to do things, etc, are suddenly completely overwhelming. It's like having the energy sucked right out of you. It's a neurological disturbance. It's essential to understand that.

There are no quick fixes. It's tempting, in this day and age, to think that somebody can take a pill and all's well again, but recovering from depression is like recovering from a really badly broken limb (as Jerod Poore points out at crazymeds). It's not like a sprain where you just need some ibuprofen and to keep the pressure off it. Your bones need to be re-set and then put in a cast for a while. You need some serious painkillers to get any sleep at all, and in the long-term you need lots of physiotherapy and follow-ups. Medication can help improve the symptoms of depression, but it's not a cure-all. For a severe or prolonged depressive illness it can take years to recover. It's okay to find this frustrating, but try not to take it out on the person who's depressed. It's not their fault.

Depression affects the way you think. Depressed thinking, by definition, is so negative that it interferes with a persons normal functioning. It happens in all sorts of situations and it becomes a downward spiral, where negative thinking causes negative behaviour. You withdraw from social situations because you think "what's the point? nobody likes me" and you stop doing things you used to love because you think "I'm crap at it anyway." None of this is rational or normal, but it's an unavoidable part of the illness.

You're not a therapist. Don't forget that you can't make it all better and you definitely can't be their therapist. The ill person has to tackle this themselves, with the help of a trained professional. You'll have a much easier time if you accept that. There are no magic words, and no advice you can give which will make it all better. Yes they may be being irrational, but it's not your job to point those things out. That stuff hurts coming from a friend in a way it doesn't coming from an impartial professional whose job it is. Literally, the most important thing for you to do is just be there. "It's okay. I'm here for you." That is honestly all it takes.

Be Supportive. So how do you support somebody who has depression? Let me show you something I wrote a few months ago when I was really low:

It's just so hard, because I look normal, so people forget that I have a disability. I wish just one person would not forget, and ask me how I am every now and then, or notice that I've not left my room for days. I really want somebody I can call to talk to when I feel low. Somebody who, once in a while, will just stay in wth me and watch movies. Put an arm around me and tell me it's okay.

It honestly doesn't take a lot. You don't have to put your own life to one side. Just call once a week to see how they are. Just that can make a world of difference, you have no idea. How happy you can make somebody just by taking the time to check in. If things are bad, and you live close enough, set aside one night a week to see them.

Procrastination. I just want to briefly mention this because I know it's been a problem for my friends and family. Letting things build up and not dealing with them until they get overwhelming is a classic symptom of depression. Especially in people who also experience anxiety (it's very common for depression and anxiety to go together). We're not lazy, we're just overwhelmed. Don't be too hard on us.

Look After You. You want to be supportive, and for that you are awesome. Seriously. It's not easy. I have had friends who were so depressed that they were completely exhausting to be around. You don't know how to help, nothing you say is right, and you don't even recognise them. They've become selfish, negative and constantly angry or upset. It's natural to feel overwhelmed, frustrated and confused. It's important that you look after yourself too. You are allowed to have boundries, and no matter how much your friend is hurting, s/he has to respect those boundries. If you feel overwhelmed or unable to deal with their problems, you get to say so. Find a helpline or a professional they can call instead. Your support is a gift and get to say how much you can handle, and when you've had too much.

To sum up: If you're concerned about somebody and you don't know what to do, don't panic. All it takes is "are you ok? Is there anything I can do?". If somebody says they are fine and they don't want to talk, then there's nothing you can do about it. You can't help somebody if they won't help themselves. If they tell you how they really feel, just listen, even if you can't relate, it still helps. Try to see the person underneath all the sadness. They may be acting totally differently, but the person you used to know IS still there underneath all of that. You might find if you just have a chat with them, make them laugh if you can, and make them feel comforted and loved, you can make a world of difference.

8 Tips For Students With Depression

Now that I am back at university, I have less time to blog. Sorry about that. But to make up for it I have compiled a list of things you really should do if you are a university student who suffers from depression. I hope you find it useful.

1. Register With a GP
Unless you're living at home while you're studying, you'll probably need to register with a local GP. It really is better to register with a practice as close to your university accommodation as possible, especially if you take medication and need regular prescriptions. Most universities provide students with contact information for near-by practices, but you can also search for a GP near you on the NHS website.

2. Get Referred to Local Psychiatric Services
Once you've registered with a local GP, it's a good idea to go see them as soon as possible and get them to refer you to local mental health services. You can also contact whoever was in charge of your care when you were at home, and ask them to write to your new GP and ask them to refer you. There are usually waiting lists, so do it sooner rather than later.

3. Meet Your Academic Contacts
All universities have a support service for students with disabilities, and it's a good idea to set up an appointment with them as soon as possible so you can ask them what they offer, and how you can access their services. Most academic departments also have their own tutors or advisors who you can go to if you have problems, so introduce yourself now and make sure they know about your condition (and bring medical evidence). It's good to have these contacts in place so that if you ever need an extension on a deadline or an exam concession, they can sort it out quickly without needing to ask questions.

4. Sign-Up For an Activity You Enjoy
Most universities have a 'Fresher's Fair' where you can find out all about the societies, sports and activities on offer. It's a really good idea to sign up for for one activity you know you will love, as an antidote to the stress of studying. Experimenting with new activities can help your self-esteem, and you might make your best friends there.

5. Buy Earplugs
If you live in a university halls of residence, trust me, you will need them at some point.

6. Avoid too much alcohol
Okay, I know it completely goes against the university stereotype and some people will think you're, like, totally uncool. However, large amounts of alcohol tend to have a chemically depressive effect on the brain. Which is a really, really bad idea when your brain is already chemically depressed. Having a couple of drinks is okay, but more than that and you could find yourself feeling extremely low, and since alcohol also makes you more impulsive, there's always the risk that you could act on suicidal thoughts. Cutting down on alcohol doesn't have to stop you socialising, just drink soft drinks, water or juice in between the alcoholic ones, so it doesn't add up to too much. If you're taking medication, always check with your doctor if it's okay to drink alcohol while you're on it.

7. Be Realistic
This is a tough one, but a very important one. Don't expect too much of yourself. There will always be some people who are more compatible with you than others, so you can't possibly get on really well with everybody. You can't read everything on your reading list. Read what you can, according to what you're going to write an essay about/talk about in a tutorial etc.

8. Apply for Disabled Student's Allowance
If you're a student and you have been diagnosed with clinical depression, or any other mental health problem, you could be eligible for Disabled Student's Allowance. DSA is a kind of government grant which helps fund extra support for disabled university students. It helps pay for any specific equipment or support you might need, like one-to-one support . You can download an application form by clicking on the link below. You'll also need a letter from a doctor or from your psychiatrist which explains that you have a diagnosed mental health condition, and how they think it might affect your studies. Click here to download an application form.

The New Antidepressant In Town

Researchers are constantly looking for new, faster-acting, more effective antidepressants with fewer side-effects. And one new antidepressant in particular is starting to look pretty promising. It's called agomelatine (brand name Valdoxan) and it isn't quite like any other antidepressant on the market, because it doesn't affect the uptake of serotonin, noradrenaline or dopamine.

Agomelatine is a specific agonist of MT1 and MT2 melatonin, and to some extent it is also an antagonist at serotonin 5HT-2C receptors (as are SSRIs). Melatonin is a hormone produced by the pineal gland, which has an important role in the sleep-wake cycle ('circadian rhythm'). Abnormalities in circadian rhythms are highly prevalent in mood disorders, including depression, so agomelatine has many potential advantages for treating depression, because it may help regulate the sleep-wake cycle. This means it helps you sleep better, without sedating you and causing daytime sleepiness. Which is a big deal, considering many SSRI's and SNRI's cause insomnia, and therefore make sleeping problems worse.

But the really big thing which makes agomelatine exciting is the lack of side effects. Unlike SSRI's and SNRI's, it does not cause weight gain, sexual dysfunction or withdrawal symptoms. It has no discontinuation syndrome. That is a big deal. Weight gain and sexual side-effects are the two main complaints people seem to have about SSRI's, and it's a big reason some people stop taking them. And trying to come of an SSRI can really suck. Not to mention how bad the discontinuation can get for venlafaxine.

As with any new antidepressant, its efficiacy is questionable. It has, however, demonstrated superior efficacy to sertraline in one study, and fluoxetine in another. In other studies, it had a higher efficiacy than placebo, especially for treating severe depression, and a lower rate of relapse. As with many antidepressants, some studies showed no difference between agomelatine and placebo. It's worth noting that those studies also showed no difference between the active controls (paroxetine and sertraline) and placebo.

If agomelatine really works, with such a good level of tolerability, it's definitely a very exciting step forward in antidepressant treatment. It was released in the UK in July this year, so watch this space.

Antidepressants: 10 Things You Need To Know

1. What Antidepressants Are
Antidepressants are drugs which are used to treat clinical depression, although many of them are approved for use in other conditions as well. There are five main types:

1. Tricyclic Antidepressants (TCAs)
2. Selective Serotonin Re-uptake Inhibitors (SSRIs)
3. Noradenaline Re-uptake Inhibitors (NRIs)
4. Multiple Re-uptake Inhibitors
5. Monoamine Oxidase Inhibitors (MAOIs)

There are also miscellaneous antidepressants which don't fit into any of those categories. Apart from depression, antidepressants may be used for severe anxiety disorders and panic attacks, obsessive-compulsive disorder, eating disorders, post-traumatic stress and chronic pain.

2. How We Think They Work
It's not known for certain how antidepressants work, but most of them are thought to work by inhibiting the reabsorption of certain chemicals in the brain. For those of you who know nothing about the brain, let me run you through a couple of basics. The brain is made up of about 10 billion brain cells, or 'neurons'. Each one connects to about 10,000 others, but they don't actually touch one another. They are separated by small gaps called synapses. This is my fantastic diagram of two brain cells:

Brain cells communicate with each other by releasing chemicals called neurotransmitters, which other brain cells respond to. These chemicals are then either broken down or re-absorbed, because otherwise your neurons would be soaking in chemicals all the time, and they wouldn't be able to respond to other neurons any more. The most common antidepressants slow down the reabsorption of certain neurotransmitters, so that your neurons get longer to respond to them. That is why they are called 're-uptake inhibitors'. The three main neurotransmitters involved in depression are thought to be serotonin, noradrenaline and dopamine. SSRI's work on serotonin, NRI's work on noradrenaline, Multiple Reuptake Inhibitors work on two or more of the three and Tricyclics work on all three.

MAOI's work a bit differently; they slow down a chemical called Monoamine Oxidase, which breaks down neurotransmitters. The effect, however, is the same. Your brain cells get to soak in the right chemicals for longer.

3. Not Everyone Needs Medication
Antidepressants should not be used for treating mild depression for two reasons:

1. Recent research shows that if you're not severely depressed, antidepressants don't work any better than placebos.
2. While the placebo effect can be useful, antidepressants have risks and side-effects, so for those with mild to moderate depression, the risks basically outweigh any potential benefits.

Here's the deal. Most people with mild or moderate depression can be treated with therapy, regular exercise, a good diet and a support group. Some people ask for medication straight away because they're looking for a quick fix, which is a dumb idea because antidepressants are not happy pills. You still need to do all those other things even if you are on medication. But there are those who do all the right things and don't feel any better. In that case, medication may be a valid option.

Severe depression is different. If you're so depressed that you spend hours lying in bed trying to get up the strength to get up and make a cup of tea, it's pretty pointless for somebody to tell you that you need to get some exercise. That's the kind of depression where you need medication straight away.

4. They Don't Work Straight Away
Some people respond almost immediately to antidepressants, but others may not notice any difference for up to a month after they start taking, or six weeks for fluoxetine (Prozac). If there's still no response after about six to eight weeks, that's when it's time to try a different drug.

5. Side-Effects
Common side-effects when you start an antidepressant are: dry mouth, nausea, headaches, sleepiness or insomnia, weight gain and constipation or diarrhoea. These effects are usually temporary and they should pass in a few weeks. SSRI's can make you anxious at first and they can sometimes cause longer-term problems with weight gain and with your sex drive. Tricyclics can affect your blood pressure, and MAOI's can have serious and potentially fatal interactions with certain types of foods. If you are prescribed an MAOI, your doctor will tell you which foods to avoid. Always read the patient information leaflet for the full list of side-effects before you take an antidepressant.

6. Suicide Risk
All antidepressants carry an increased risk of suicide. Therefore it's very important that anybody who is starting an antidepressant is carefully monitored by a doctor, and that they report any suicidal thoughts immediately. It's a good idea to keep a list of phone numbers you can call in a crisis, and this should include your doctor or therapist or a crisis team. The risk of suicide associated with antidepressants is a lot higher in children and teenagers.

7. Alcohol
Generally speaking, it's best to avoid alcohol if you're taking an antidepressant. A few drinks here and there or a glass of wine with your meal is usually okay, but some combinations should not be mixed with alcohol at all. Ever. So ask your doctor first. Large amounts of alcohol also tend to make you more depressed, which can further increase your risk of suicide in the first few weeks of treatment.

8. Physical Dependency
When you've been taking an antidepressant for a while, your brain gets used to the chemical changes the meds cause. Although antidepressants aren't addictive in the true sense of the word, some people experience withdrawal symptoms when they stop taking their medication especially if it's an SSRI, and even more so if you stop taking them abruptly. Withdrawal from reuptake inhibitors can cause severe fatigue, headaches, nausea, vomiting, chills, dizziness, shaking or tremors, insomnia, electric-shock like sensations, vertigo, confusion and suicidal thoughts, plus "brain shivers". These symptoms are collectively known as SSRI Discontinuation Syndrome, but multiple reuptake inhibitors which affect serotonin can also cause this. Don't try to come off your medication on your own. You need to gradually reduce your dose over time to avoid withdrawal effects. Also, some drugs leave the body very quickly so even if you only miss one dose you can experience withdrawal symptoms. It's important to take your meds at the same time every day (or however often your psychiatrist or pharmacist told you to). Getting a pill organiser is a good idea.

9. Sometimes They Stop Working
SSRI's and other reuptake inhibitors can work really well at first and then suddenly stop working. It's known as the 'poop-out' effect. I kid you not, that's what doctors call it. It usually just means you need to switch to another medication in the same class, so don't panic if you find your medication suddenly stops working. Luckily, if you take a break from an antidepressant then start taking it again, it will often work as well as it did when you took it the first time. So if you find two SSRI's that work well for you, but they tend to quit working after a while, you can cycle between the two of them for as long as you need to.

10. Antidepressants Are Not A Cure
For people with severe depression, medication can be a very important part of treatment. It can be the difference between being completely incapacitated, and being able to engage in therapy, being able to go for a walk etc. But antidepressants aren't a magic cure. They don't suddenly make everything okay. Severe mental illness can't be fixed overnight. It usually takes months or even years of treatment to reach some sort of stability where you can get back to your life as it was before you became ill. And non-drug treatments are just as important for people who take medication as they are for those who don't. Doctors, patients, friends, family etc often expect medication to make the problem go away straight away. Some people will even wonder why you can't just "snap out of it" already. It doesn't work like that. Recovering from a serious depressive illness is like recovering from major surgery. It takes time, and the right treatment.

Just a reminder: I'm not a doctor and this is not a replacement for proper medical advice. You should always consult the patient information leaflet for a medication before taking it.

Fact.

The Physiology of Depression

The physiology of mood disorders is complicated, and not particularly well understood. What we do know comes from brain imaging and looking at the levels of different chemicals in the brain. There may be some long, confusing words you've never heard of here, but stick with it, because what this stuff tells us is important.

In unipolar depression, the physical problem is believed to be an imbalance of either serotonin, noradrenaline or dopamine in the brain; or two or all three of those. Exactly how we don't know, and the exact imbalance is probably different for everybody, but generally speaking, most people with depression have less serotonin, or noradrenaline in their brain than healthy people do. The pathophysiology of Bipolar Disorder is poorly understood, but it is probably linked to the same three neurotransmitters as well as some structural abnormalities in the amygdala, basal ganglia and prefrontal cortex.1

PET (Positron Emission Topography) and SPECT (Single Proton Emission Computed Topography) scans are two types of brain scans which show how active or inactive the different areas of the brain are. PET scans of depressed brains compared to normal ones show a significant reduction in overall brain activity. This is why everything seems ten times harder when you're depressed and why it's much harder to concentrate and remember things. People with depression are like cars running on half a tank of gas, or in some cases hardly any gas at all. You can barely get out of the driveway, let alone make it around the block. In other words, if you're depressed, you can't expect yourself to carry on with your normal life while you are ill. So give yourself a break!

In people with Bipolar Disorder, PET and SPECT imaging usually shows decreased activity in the prefrontal cortex, which is involved in emotion and planning, the amygdala, which is associated with mood regulation, and the hippocampus2. This may explain the intense highs and lows bipolar sufferers experience. Patients in the depressed phased of a cycle show very similar scan results to patients with unipolar depression. In the manic phase, imaging shows both left-right and dorso-ventral asymmetry in the basal temporal cortex. I have absolutely no idea what that means.

But whether you have any idea of what a basal temporal cortex is or not, the important thing to understand is that...

[in serious mental illness] Your brain is physically injured, and like any other part of the body that has received a physical injury, it needs the proper care to heal... The problem that far too many people have is that they can't see the injury, therefore it is not a real injury... - Jerod Poore, Crazy Meds 3

Whether you suffer from a mood disorder or not, you should know that they are genuine medical conditions with physical manifestations in the brain. Just because you can't see the physical problem, it doesn't mean that it's not there. If you could have one of those fancy brain scans yourself, you would see it. Use this information to accept the fact that you're ill, and you need rest and medical treatment. You're not weak or selfish or any of the other things people may accuse you of. You're not well. Got it? Good.

Sources:
1. Internet Mental Health
2. Rachel Pollock, PhD & Irving Kuo, MD - "Neuroimaging in Bipolar Disorder"
3. Jerod Poore, Crazy Meds
4. Karl Hempel, MD - "Depression: What You Need To Know"
5. Amen Clinics SPECT Imaging

Other Types of Depression

So if you read the first on depression, you know what clinical depression is, the symptoms and some of the possible causes. But there are other types of unipolar depression too.

Dysthymia
Dysthymia (or Dysthymic Disorder) is a form of depression which is less severe than major depression, but which is chronic and persistant. People are diagnosed with Dysthymia if they have felt depressed more than half of the time for at least two years, but their depressed mood is either not severe enough to justify a diagnosis of clinical depression or it only occurs in shorter episodes. However, it's common for Dysthymia to lead to a diagnosis of clinical depression: 75% of people with Dysthymia will go on to develop clinical depression within 5 years of being diagnosed.

The diagnostic criteria are as follows:
A. Depressed mood more than half the time for at least 2 years.
B. When depressed, two or more of the following symptoms are present:
(1) Appetite increased or decreased
(2) Sleep increased or decreased
(3) Fatigue
(4) Poor self-image
(5) Attachment to relatives other than parents
(6) Concentration and decisiveness decreased
(7) Feelings of hopelessness or pessimism.
C. During the 2-year period, symptoms were not absent for 2 months or longer.
D. During first 2 years, the patient has not had a Major Depressive Episode
E. Patient has never had a manic, hypomanic or mixed state.
F. Patient has never met the criteria for Cyclothymia

Seasonal Affective Disorder
Seasonal Affective Disorder (SAD) is a condition which is characterised by normal mental health most of the year, with symptoms of depression only occuring during the winter months. The symptoms normally begin in September and get worse as the winter progresses, starting to go away in early spring. Up to eight in 10 people experience some tiredness, increased appetite or anxiety in the winter months because of the low levels of bright light. When light enters the eye, it stimulates nerve impulses to travel to the hypothalamus - the part of the brain which controls mood, appetite, sleep, temperature and sex drive. So when light levels decrease in the winter, all of those things are affected.

Light therapy has been shown to be effective in up to 85 per cent of diagnosed cases of seasonal affective disorder. It involves sitting in front of a special lamp or light box which is about ten times brighter than normal household lighting. In mild cases just making the effort to spend time outside in the daylight may be of benefit. In severe cases, antidepressants may be used, but this is not ideal because they can make some of the symptom, like sleep problems, worse rather than better.

In some rare cases people experience a form of SAD in the summer months. The symptoms of Summer SAD are pretty much the opposite, including insomnia, weight loss, agitation, reduced appetite, irritability and increased sex drive.

Postnatal Depression
Also known as Postpartum Depression (PPD). PND is a type of depression which affects many women after they give birth. It can start at any time within a year of the birth, but it most commonly starts in the first 4-6 weeks. As many as one in ten new mothers experience PND, often without recognising it, and the longer the illness goes untreated, the longer it's likely to last. PND is a temporary and very treatable condition.

If you have any of the following warning signs, it's vital that you seek medical attention as soon as possible, or report your feelings to your health visitor.

1. Feeling very sad or low, crying a lot.
2. Feeling very tired, or 'numb' and not wanting to do anything or not having interest in the baby.
   
3. Feeling hopeless and like you can't cope, and feeling very guilty as a result. 
4. Feeling like you're not attached to your baby, or thinking that you're a bad mother because you don't love your baby enough.
5. Being unusually irritable, which may make you feel even more guilty.
6. Having problems sleeping 
7. Losing your appetite
8. Losing interest in sex
   
9. Being hostile or indifferent to your partner or your baby
10. Feeling very anxious, worrying constantly about the baby or your own health, or having panic attacks
11. Feeling unable to concentrate or finding normal tasks overwhelming
12. Thoughts about death or suicide

Thoughts about death can be very frightening, and may make you feel as if you are going mad or completely out of control. These feelings are common, and they don't automatically mean that you will hurt yourself or your baby, but it is extremely important that you talk about them. Many women are afraid to talk to anyone about their symptoms, out of fear that their baby might be taken away or they may be labelled a bad mother, but it's very important that you do get treatment. Doctors and health visitors deal with PND all the time; they won't judge you for it.

It's now becoming recognised that fathers can also suffer from depression after the arrival of a new baby, especially if the mother is suffering from PND. Having a new baby brings lots of stressful changes, like increased responsibility, worrying about the cost of raising a child, changes in the relationship between the parents, having more stress and jobs to do at home as well as not having as much sleep. Men sometimes feel hostile and angry when they are depressed, and this can lead to guilt, plus home visitors or health workers might be critical of them or see them as potentially violent. Again, symptoms should be discussed with a doctor as soon as possible to prevent harm to the child or to the relationship between father and mother.

Sources:
The Mental Health Foundation
MIND
Internet Mental Health

Bipolar Depression

Bipolar Depression is a kind of mood disorder which causes periods of low or depressed mood like those which people with unipolar depression experience, but people with bipolar depression also have periods of elevated mood, which can be either 'mania' or 'hypomania'. It's also known as Manic Depression or Bipolar Disorder.

Somebody who is having a manic episode usually feels elated or euphoric, but it can also make people irritable. They may be easily distracted, have a low attention span, increased sex drive, unusual impulsive behaviour and racing thoughts. Sometimes a person can become aggressive, feel unstoppable, or have delusional ideas such as that they are "chosen" or "on a special mission". At its most severe, manic symptoms can progress to full-blown psychosis.

Hypomania is a shorter and less extreme version of mania, still with elevated or irritable mood but with fewer symptoms and less severity. A 'mixed episode' is one where symptoms of depression and mania are present at the same time.

There are three specific types of Bipolar Disorder - Bipolar I, Bipolar II and Cyclothymia. Some people, however, may have an illness which seems to be a kind of bipolar depression but they don't fit into any of the three categories. Those people might be technically labelled with 'Bipolar Disorder Not Otherwise Specified'.

Bipolar I Disorder

1. People with Bipolar I will have had at least one full manic episode.
2. A diagnosis of Bipolar I requires only the presence of one manic episode, but many people with Bipolar I experience periods of major depression or hypomania as well.
3. Bipolar I is the most severe form of Bipolar Depression.

Bipolar II Disorder

1. Bipolar II is characterised by cycles of depressed episodes and hypomanic episodes.
2. To be diagnosed with Bipolar II, the sufferer has to have had at least one hypomanic episode, and at least one major depressive episode.
3. Only people who have never had a manic episode are diagnosed with Bipolar II. If somebody with Bipolar II experiences a manic episode, their diagnosis will be changed to Bipolar I.

Cyclothymia:

1. Cyclothymia is a chronic type of Bipolar Depression where hypomanic episodes are present chronically for at least 2 years, but without any periods of clinical depression
2. People with Cyclothymia can experience chronic low mood, but not severe enough to quality as a major depressive episode, so they do not fulfull the criteria for a diagnosis of Bipolar II.
3. The longest period somebdoy with cyclothymia has been free of symptoms is two months. If it's more than that, they will be given a different diagnosis.

Bipolar depression is a lot less common than unipolar depression, but it is also thought to be under-diagnosed. Campaigners say that only around 50% of people with Bipolar Disorder are diagnosed and for those who are it takes, on average, 8 years to be properly diagnosed.1 An article in the Independent quoted Michelle Rowett, chief executive of MDF, The Bipolar Organisation, as saying:

"Bipolar has the highest suicide rate out of all mental illnesses... So people not treated soon enough are having their lives put at risk."2

It's also poorly treated. Only around 5 per cent have psychological therapy and just a third of known sufferers have a yearly check of their state of mind.3 Many famously creative individuals are known or believed to have suffered from bipolar disorder, e.g. Vincent Van Gough, Spike Milligan, Sylvia Plath, Virginia Woolf, and Ernest Hemingway. Stephen Fry, a much-loved British actor and comedian, is one such example. He has openly admitted to having manic depression - specifically cyclothymia.4 He famously walked out on a part in a West End show called Cell Mates and disappeared. It later emerged that he had tried to kill himself, then took a ferry to France and eventually went to America for treatment. Of his own diagnosis, he said, and I quote:

"I'd never heard the word before, but for the first time, at the age of 37, I had a diagnosis that explains the massive highs and miserable lows I've lived with all my life ... There's no doubt that I do have extremes of mood that are greater than just about anybody else I know. The psychiatrist in the hospital recommended I take a long break... My mind was full of questions. Am I now mad? How have I got this illness, could it have been prevented, can I be cured of it? Since then, I have discovered just how serious it is to have bipolarity, or manic depression as it's also called. Four million others in the UK have it and many of them end up killing themselves."5

Bipolar disorder has the highest suicide rate of any psychiatric illness. Around 15% of sufferers kill themselves. This makes the shockingly low rate of diagnosis and proper care for those with the illness all the more worrying. For more information, try the following resources:

1. MDF: The Bipolar Organisation
2. Bipolar Aware
3. The Mental Health Foundation
4. Rethink

Sources:
1, 2, 3. The Independent, "Stephen Fry: My Battle With Mental Illness"
4. BBC "The Secret Life Of Depression" microsite
5. Stephen Fry - "The Secret Life Of Depression"

What Is Depression?

Depression is a mental illness which involves feelings of intense sadness, hopelessness and low self-esteem which won't go away, along with physical symptoms like sleeplessness, a loss of energy, or physical aches and pains. Depression is different from feeling low, even though people often say "I'm depressed" when they feel a bit down. Mild to moderate depression is common, and while it usually doesn't stop you from doing your normal daily activities, it does make everything harder to do and seem less worthwhile.

Severe depression is extremely distressing and makes normal activity near impossible. It can be life-threatening, since many people with severe depression attempt suicide. Somebody with severe depression might stay in bed for days or weeks on end because they don't have the energy to do anything else. This kind of depression gets you labelled with 'Major Depression' or 'Major Depressive Disorder'. It is also sometimes called 'unipolar' depression, to distinguish it from bipolar depression.

Symptoms
The most common symptoms of depression are:

1. Low mood, which varies little from day to day.
2. Loss of interest, pleasure and concentration
3. Loss of energy, tiredness even after little effort.
4. Loss of appetite, or increased appetite
5. Weight loss when not dieting or weight gain
6. Insomnia & sleeplessness, or excessive sleepiness
7. Visible agitation or slowed movements
8. Feelings of worthlessness, low self-esteem, low self-confidence
9. Excessive or inappropriate feelings of guilt
10. Loss of sex drive
11. Thoughts about suicide or suicide attempts

As a general rule, if you have experienced four or more of these symptoms, for most of the day nearly every day, for over two weeks, then you should seek help. Very severe depression is sometimes also accompanied by psychotic symptoms, like hallucinations or delusions.

Causes
The exact cause of depression is not known, but the likelihood that somebody will decome depressed seems to be determined by a combination of physical, psychological and social factors.

Some types of depression run in families, so it's thought that some people inherit a genetic predisposition for it. In identical twins, if one twin is diagnosed with clinical depression, the other twin has around a 46% chance of developing one too. Other people affected by depression have no family history of mental illness, but they may be vulnerable to depression because they have picked up very negative ways of thinking. Low self-esteem and distorted thinking are closely related to depression, although it's not always clear if they are a cause or an effect.

Depression can be triggered by a traumatic event or period of stress, such as a bereavement, losing a job, family problems, divorce, exam stress, poverty or social isolation. Substance abuse and certain chronic illnesses (e.g. hypothyroidism) also make people more likely to develop depression.

More about depression:

• Bipolar Depression
  
• Other types of Depression
  
• Physiology of Depression
  
• Advice For Friends and Family

Sources:
1. The Depression Alliance - Now We're Talking (April 17, 2007)
2. NPR - History of Treating Depression (2004)
3. Karl Hempel, M.D. - Depression: What you need to know