What is depression?
How serious is depression?
What causes depression?
What are the drug treatments for depression?
What lifestyle changes can help depression?What Is Depression?
Everyone experiences some unhappiness, often as a result of a change, either in the form of a setback or a loss, or simply, as Freud said, "everyday misery". The painful feelings that accompany these events are usually appropriate, necessary, and transitory and can even present an opportunity for personal growth. However, when depression persists and impairs daily life, it may be an indication of a depressive disorder. Severity, duration, and the presence of other symptoms are the factors that distinguish normal sadness from a depressive disorder.
Depression has been alluded to by a variety of names in both medical and popular literature for thousands of years. Early English texts refer to "melancholia," which was for centuries the generic term for all emotional disorders. Depression is now referred to as a mood disorder, and the primary subtypes are major depression, chronic and usually milder depression (dysthymia), and atypical depression. Other important forms of depression are premenstrual dysphoric disorder (PDD) and seasonal affective disorder (SAD). (The other major mood disorder, not discussed in this report, is bipolar disorder, or manic-depressive illness, which is characterized by periods of depression alternating with episodes of excessive energy and activity [see Well-Connected Report # 66, Bipolar Disorder])
In major, or acute, depression, at least five of the symptoms listed below must occur for a period of at least two weeks, and they must represent a change from previous behavior or mood. Depressed mood or loss of interest must be present.In addition, other criteria must be met: the symptoms listed above should not follow or accompany manic episodes (such as in bipolar or other disorders); they should impair important normal functions (such as work or personal relationships); they are not caused by drugs, alcohol, or other substances; and they are not caused by normal grief [see below]. One long-term study found that episodes of major depression usually last about twenty weeks.
1. Depressed mood on most days for most of each day. (Irritability may be prominent in children and adolescents)
2. Total or very noticeable loss of pleasure most of the time.
3. Significant increase or decrease in appetite, weight, or both.
4. Sleep disorders either insomnia or excessive sleepinessnearly every day.
5. Feelings of agitation or a sense of intense slowness.
6. Loss of energy and a daily sense of tiredness.
7. Sense of guilt and worthlessness nearly all the time.
8. Inability to concentrate occurring nearly every day.
9. Recurrent thoughts of death or suicide.
Symptoms of depression in children may differ from those in adults. Symptoms include persistent sadness, an inability to enjoy favorite activities, increased irritability, complaints of physical problems such as headaches and stomach aches, poor performance in school, persistent boredom, low energy, poor concentration, or changes in eating or sleeping patterns or both. In one study, depressed children had a greater tendency to bully others, while anxious children were more often bullied.
Chronic Depression (Dysthymia).
Chronic, but mild depression, or dysthymia, is characterized by many of the same symptoms that occur in major depression but they are less intense and last much longerat least two years. The symptoms have been described as a "veil of sadness" that covers most activities. Typically, there are no disturbances in appetite or sexual drive; mania, severe agitation, and sedentary behavior are not present. Suicidal thoughts are not usually present. Possibly because of the duration of the symptoms, patients who suffer from chronic depression do not exhibit marked changes in mood or in daily functioning, although they have low energy, a general negativity, and a sense of dissatisfaction and hopelessness. They may suffer from episodes of major depression; in such cases, the condition is known as "double depression". The family life of such patients is often impaired because of their decreased level of emotional, psychic, and physical energies.
People with atypical depression generally overeat, oversleep, have a general sense of heaviness, and have strong feelings of rejection.
How Serious Is Depression?
Risk for Suicide.
Suicidal preoccupation or threats of suicide, especially from someone known to be unhappy or suffering from a recent loss, should be considered serious. Depression is estimated to contribute to 50% of all suicides. It is a major cause of death in young people, and any child with signs of severe depression or who expresses suicidal thoughts should be seen by a mental health professional as soon as possible. Suicide in the elderly is the third-leading cause of death related to injury; men account for 81% of these suicides, with divorced or widowed men at highest risk.
Effect on Physical Health.
Depression is now known to play a major role in exacerbating existing medical conditions and may even predispose people to disease. Studies indicate that depression may have adverse biologic effects on the immune system, blood clotting, blood pressure, blood vessels, and heart rhythms. The health of elderly people who are depressed when admitted to the hospital is likely to decline, and they are less likely to fare well during the recovery period than are elderly patients who are not depressed. Many studies have now shown strong associations between depression and an increase in the incidence and severity of strokes and heart attacks.
Heart Disease and Heart Attacks. In one 30-year study, men who were clinically depressed had a greater risk for heart disease and heart attack than men who were not depressed; this increased risk lasted for decades. Although some studies have failed to show an association between depression and heart disease in women, a recent study reported that depression is a significant risk factor for death in older womenparticularly from heart diseaseand the risk is equal to that from smoking or high blood pressure. Depression may even impair a patient's response to medication for heart disease. The more severe the depression, the more dangerous to the health, although some studies have indicated that even mild depression, including feelings of hopelessness, experienced over many years may harm the heart in people with no early signs of heart disease.
Stroke. Depression appears to increase the risk for stroke in both women and women. Researchers speculate that depression and stroke might have common patterns of development. Brain scans in the elderly, for example have reported greater atrophy in the brains of depressed individuals than in those of nondepressed ones.
Other Diseases. Some studies have linked past and current major depression with bone loss in women. Depression coincides with high pain scores in people with rheumatoid arthritis. In a study of elderly Japanese patients, the highest mortality rate occurred among those who were severely depressed, with cancer, suicide, and pneumonia as significant causes of death. (An unusually high suicide rate among those over 65 in Japan may, however, be specific to the culture.)
Impotence. In one study of 1,700 men ages 40 to 70, those who reported moderate to total impotence were 82% more likely to be depressed than men with no erectile problems. Researchers speculate that depressed men may be more self-critical and have less sexual desire than non-depressed men; both factors may effect performance. Depression may also have a direct effect on the nervous system that could lead to erectile problems. On the other hand, erectile dysfunction can cause depression, and the two conditions could perpetuate each other.
Increased Risk for Addictions. Severely depressed people are at high risk for alcoholism, smoking, and other forms of addiction. Pregnant women who drink may be increasing their child's risk for a future mental illness, as well as increasing their risk for delivering children with birth defects.
Impact on Others.
Effects on the Health of Offspring. One study has found that children of depressed parents are at greater risk for many medical conditions (e.g., urinary and genital disorders, headaches, lung problems) and hospitalizations. The association between depression in children and medical disorders was apparent only when either one or both parents were depressed. (In other words, depressed children whose parents did not suffer from mood disorders were at no higher risk for medical disorders.)
Effects on Marriage.
In one survey, nearly half of people who suffered from psychiatric disorders before or during their first marriage were divorced, compared to a divorce rate of 36% in those who those who never suffered from emotional disorders.
Effects on Jobs.
In one British study, 60% of personnel directors said that they would never hire anyone for an executive position who had been previously diagnosed with depression. About a quarter of these professionals felt that formerly depressed people couldn't even handle clerical or manual jobs. (As a comparison, only 3% of personnel directors said that they thought diabetes would impair anyone's performance.) This strong bias against psychiatric disorders may be higher in England than in some other countries, but it is still indicative of the prejudices present in many cultures that inaccurately and unfairly separate psychologic from physical conditions when assessing capability.
What Causes Depression?
Patients who have had serious bouts of depression usually cite a stressful life event as the precipitating factor for their illness. Recent loss of a loved one is the most frequently reported precipitant of acute depression, but all major (and even minor) losses cause grief. Traumatic events, such as a sudden loss of a loved one, abuse, or even natural events such as earthquakes, can cause severe immediate or delayed depression, from which recovery takes a long time. Most people are able to cope with the emotional pain and eventually move beyond it without becoming chronically depressed. People who do develop acute or chronic depression after loss may have predisposing factors, including genetic or biologic ones, that make them more vulnerable. The existence or absence of a strong social network of family, friends, or both also has a major positive or negative effect, respectively, on recovery.
Neurotransmitters. Neurologic factors appear to play a primary role in major depressive episodes. Depression is linked to abnormalities in neurotransmitters (chemical messengers in the brain)most importantly, serotonin, acetylcholine, and a group of neurotransmitters known as catecholamines (which consist of dopamine, norepinephrine, and epinephrinealso called adrenaline). The degree to which these chemical messengers are disturbed may be determined by other factors such as light or genetic susceptibility. For example, researchers have identified a defect in the gene known as SERT, which regulates serotonin, that has been linked to depression.
Hormones. The role of hormones in depression is not clear, but female hormones play roles in premenstrual dysphoria, postpartum depression, and SAD. These forms of depression recede or stop after menopause. Researchers are looking at certain steroid hormones in the brain that regulate progesterone and the activity in areas of the brain that control reproductive hormones. Low levels of these steroids may play a role in depression.
Changes in Brain Structure. Brain scans have shown that a particular area of the brain (the prefrontal lobe) that influences emotional control and regulates serotonin production is less active and considerably smaller in elderly depressed people than in those who do not suffer from depression. The more severe the depression the greater the atrophy in the brain.
Other Possible Causes of Depression.
Medications. Many drugs, such as beta-blockers, corticosteroids, antihistamines, analgesics, and anti-parkinsonism medications, can cause depression. Withdrawal from many medications can also cause depression.
Infections. Studies are finding a higher rate of mood disorders among people born to mothers who were pregnant during flu outbreaks; the risk seems to be greatest during the second trimestera crucial developmental period for the brain.
What Are the Drug Treatments for Depression?
Antidepressants are very effective; one study reported that up to 90% of patients with major depression will improve with good compliance and adequate doses of the right antidepressant drug. Side effects can be avoided or moderated if the regimen is started at low doses and built up over time. Current antidepressants are not addictive. A great deal of leeway exists in choosing an appropriate antidepressant; overall, they seem to be equally effective, although individual responses vary. Lack of compliance is probably the major barrier to success; for example, according to one study, as many as 70% of elderly depressed patients do not adhere to antidepressant drug regimens. Some patients with accompanying problems, such as anxiety, may require additional drugs that treat those symptoms.
For people who have never been treated for depression, medications are usually maintained for six months or longer after depression has been resolved. Patients who improve within two weeks of taking medications may not require lengthy treatment. Some patients may require indefinite maintenance therapy. These patients include those who have had three or more recurrences of depression, people over 50 who have never had major depression before, those with two episodes and a family history of depression or bipolar disorder, and people who have had severe, sudden, or life-threatening depressions within the past five years. Most patients have a recurrence of depression within five years after treatment has stopped.
Virtually all antidepressants have side effects and complicated interactions with other drugssome are very serious. Some are mentioned in the individual drug discussions below, but many are not, and patients should inform the physician of any drugs they are taking, including over-the counter-medications. There is an increased risk of oral health problems caused by dry mouth associated with long-term use of all antidepressants. The risks appear to be highest with heterocyclic antidepressants, with multiple drug use, and with the presence of oral infections. Patients can increase salivation by chewing gum, taking vitamin C tablets, using saliva substitutes, and rinsing the mouth frequently. Abrupt withdrawal from many antidepressants can produce severe side effects; no antidepressant should be stopped abruptly without consultation with a physician.
Selective Serotonin-Reuptake Inhibitors and Other Designer Antidepressants.
Selective serotonin-reuptake inhibitors (SSRIs) are now the first-line treatment of major depression. They work by increasing levels of serotonin in the brain. Because they act on serotonin specifically, they have fewer side effects than tricyclic antidepressants, which affect a number of chemicals in the body. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa).
Benefits of SSRIs. SSRIs appear to help people with most forms of depression including mild to moderately severe major depression, seasonal affective disorder, and dysthymia. SSRIs are even proving to be effective for premenstrual dysphoric disorder. In fact, in such cases, intermittent fluoxetine therapy (taking the drug only during the 14-day premenstrual period) may be as effective as continuous therapy and be associated with fewer adverse effects. SSRIs also benefits people other disorders, including obsessive-compulsive disorder, panic disorder, and bulimia. They also reduce impulsive aggressive behavior in both psychiatric patients and in people with no mental health problem. Patients taking SSRIs report not only relief of depressive symptoms, but also a higher level of efficiency, more energy, and better relationships with other people. Fluoxetine appears to be safe for pregnant women and the developing fetus, although pregnant women should avoid any medications, if possible. Antidepressants have been detected in mother's milk, although one study found no adverse effects on one-year old infants whose mothers took SSRIs while nursing their young.
Duration of Effectiveness and Use. It takes two to four weeks for SSRIs to be effective in most adults and longerup to 12 weeksin the elderly and those with dysthymia. By 14 weeks, depression should be in remission in everyone who responds to the drugs. Unfortunately, recurrence is common once the drugs are stopped. One recent study of patients taking fluoxetine suggested that patients should continue taking Prozac for 38 weeks to prevent relapse. Another study examined patients using paroxetine and found that those who continued with the full dose of Paxil for 28 weeks had half the chance for relapse when compared to those who reduced their dose.
Side Effects of SSRIs. The most common side effects are nausea and gastrointestinal problems. Others include anxiety, drowsiness, sweating, headache, difficulty sleeping, and mild tremor. These effects usually wear off over time. During the first few weeks of treatment, some patients lose a small amount of weight, but, in general, they regain it.
Sexual dysfunction, including delayed or loss of orgasm and low sexual drive, occurs in 30% to 40% of patients on SSRIs and account for a substantial amount of noncompliance. (Citalopram, a newer SRRI, may pose a lower risk than other SSRIs for this side effect.) Taking a supervised drug "holiday" on the weekend may improve sexual function during that time. (Withdrawal symptoms may develop and include return of depression, sleep problems, exhaustion, and dizziness. Prozac, with its longer duration of action, appears to be associated with a lower risk for withdrawal symptoms than shorter-lasting SSRIs, but a weekend off this drug may not be long enough to restore sexual function.)
Elderly people taking these drugs should take the lowest dose possible, and those with heart problems should be monitored closely. SSRIs can cause agitation, impulsivity, nausea, and dry mouthwhich can increase the risk for cavities and mouth sores. The elderly are at increased risk for falling. (It has been thought that SSRIs posed less of a risk for falls and hip fractures than other antidepressants, but recent studies indicate that, in this regard, they are no safer.) Over the years, some patients taking SSRIs have reported a group of side effects, known as extrapyramidal symptoms, which are similar to those in Parkinson's disease and affect the nerves and muscles controlling movement and coordination. They are uncommon and when they develop they tend to occur within the first month of treatment.
High doses or interactions with other drugs may cause hallucinations, confusion, changes in blood pressure, stiffness, and irregular heart beats. Death from overdose is extremely rare. Serious interactions can occur with certain drugs, including other antidepressants, such as tricyclics andof particular noteMAOIs [see below]. Other serious interactions have occurred with Demerol, illegal substances such as LSD, cocaine, or "ecstasy", and the antihistamines terfenadine (Seldane) and astemizole (Hismanal). (Seldane has been taken off the market). Any medication must be taken with caution during pregnancy. People may drink alcohol in moderation, although it may compound the drowsiness experienced with SSRIs; some SSRIs increase the effects of alcohol.
Heterocyclic and Other Designer Antidepressants. A number of drugs are being designed that, like the SSRIs, target specific neurotransmitters that regulate depression. Most act on mechanisms that elevate both serotonin and noradrenaline and some may be more effective for severely depressed patients than are the SSRIs. Some are known as heterocyclic antidepressants. These drugs tend to have fewer adverse effects on sexual function than SSRIs, and some people have reported enhanced sexuality with some of them. It should be noted that most of these "designer" drugs are still new, and widespread use may increase reports of adverse effects. Common side effects include drowsiness, nausea, dizziness, and dry mouth, but drugs vary in others effects. Dry mouth is a particular problem with long term use of heterocyclics.
Bupropion. Bupropion (Wellbutrin) is particularly promising for a number of conditions, including it use as a treatment for quitting smoking (Zyban). It causes less sexual dysfunction than SSRIs. Side effects include restlessness, agitation, sleeplessness, headache, rashes, stomach problems, and in rare cases, hallucinations and bizarre thinking. Weight loss occurs in about 25% of patients. High doses increase the risk for seizures, particularly in those with eating disorders or those with other risk factors for seizures.
Venlafaxine. Venlafaxine (Effexor) is another designer antidepressant that is gaining popularity. In one comparison study, venlafaxine was similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. In a group who required higher doses of an antidepressant in order to obtain a response, venlafaxine was slightly more effective. Venlafaxine has a variety of side effects, and high blood pressure and depressed central nervous system function can occur in high doses. Some patients report severe withdrawal symptoms, including dizziness and nausea.
Nefazodone. Nefazodone (Serzone) has less severe side effects, including sexual dysfunction, than SSRIs. The drug can also be combined with SSRIs. However, it may cause an abrupt drop in blood pressure after standing up suddenly.
Other Designer Antidepressants. Mirtazapine (Remeron) and maprotiline (Ludiomil) are other effective antidepressants that have few side effects. In one trial of patients with a high incidence of severe depression, mirtazapine was more effective than fluoxetine and it had fewer side effects. Maprotiline increases the chance for seizures in high-risk people and may cause heart rhythm disturbances.
Before the introduction of SSRIs, tricyclics had been the standard treatment for depression. Some of the most frequently prescribed tricyclics are amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), protriptyline (Vivactil), and trimipramine (Surmontil).
Benefits of Tricyclics. Tricyclics are as effective as SSRIs and may still offer benefits for many people with chronic depression who do not respond to SSRIs. Imipramine has been shown to be of particular benefit for those with dysthymia. The tricylclic protriptyline (Vivactil) appears to help people with tension headaches.
Side Effects of Tricyclics. Side effects are fairly common with these medications, and those most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Blood pressure may drop suddenly when sitting up or standing. The tricylclic protriptyline (Vivactil) is associated with weight loss and causes less drowsiness than does Elavil. It can, however, cause insomnia and nightmares if the drug is taken too close to bedtime. Protriptyline also causes sun sensitivity and people who took this should take precautions against sunlight when they go outdoors.
Tricyclics can have serious, although rare, side effects and can cause fatal overdose. Tricyclics may pose a danger for some patients with certain heart diseases. One study comparing nortriptyline with paroxetine, an SSRI, reported nine times more adverse cardiac events with the use of the tricyclic than with the SSRI. Also of concern is a recent study reporting that tricyclics, particularly imipramine, may be responsible for 10% of cases of a lung disease called idiopathic pulmonary fibrosis (IPF), which can cause lung inflammation and scarring. Initial symptoms are breathlessness and dry cough. (Two other investigative tricyclics, mianserin (Bolvidon) and dothiepin (Prothiaden), also increased the risk.)
Monoamine Oxidase Inhibitors (MAOIs).
Monoamine oxidase inhibitors (MAOIs) are usually indicated when other antidepressants prove ineffective. They may be effective for atypical depression and for people with eating disorders, post-traumatic stress disorder, and borderline personality. MAOIs include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate). One recent study reported that a patch form of an MAOI worked much faster than an oral form, which takes up to six weeks to be effective. MAOIs commonly cause orthostatic hypotension (a sudden drop in blood pressure upon standing), drowsiness, dizziness, sexual dysfunction, and insomnia. The most serious side effect is severe hypertension, which can be brought on by eating certain foods having a high tyramine content. Such foods include aged cheeses, most red wines, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans, and concentrated yeast products. MAOIs also can cause birth defects and should not be taken by pregnant women. MAOIs can have serious interactions with a number of drugs, including some common over-the-counter cough medications, psychostimulants (such as Ritalin), and decongestants. Very dangerous side effects can occur from interactions with other antidepressants, including SSRIs. There should be at least a two to five-week break between taking MAOIs and other antidepressants. (A European MAOI, moclobemide, appears to be safe when used with an SSRI, but it is not yet available in the U.S.)
Other Promising Treatments.
Estrogen. Estrogen replacement therapy (ERT) may relieve menopausal-associated depression and even relieve depression in elderly women who do not respond to standard antidepressants. ERT has other health benefits and risks, which a physician should discuss with the patient. (Hormone replacement therapy that contains both progesterone and estrogen may cause mild depression.) One study showed that estrogen given under the tongue (sublingually) successfully relieved the symptoms of postpartum depression, whereas antidepressant therapy and counseling provided only temporary relief.
St. John's Wort. St. John's Wort (Hypericum perforatum) is an herbal remedy that is helping mild to moderate depression in many patients. It is widely prescribed in Germany, and one short-term British study reported that it was effective and had fewer side effects than standard antidepressants. A long-term trial is now underway in the U.S. to determine its safety and effectiveness. Even those with mild depression should not use St. John's Wort without consulting a physician. This herbal substance is not regulated and there is no guarantee of quality in any brands currently available. The product should contain at least 0.3% hypericin, the active substance in St. John's Wort. Although no dose levels have been established, trials indicate that 300 milligrams taken three times a day may be effective. It takes between two and three weeks for the drug to have an effect. Common side effects include gastrointestinal problems, dry mouth, allergic reactions, and fatigue. It may also increase sensitivity to the sun, and some people have reported temporary nerve damage after sun exposure. People with severe depression, children, and pregnant or nursing women should not take this substance. It should never been combined with other antidepressants. Studies indicate that the herbal substance may be similar to MAOI inhibitors. Some experts, then, suggest avoiding high amounts of foods and substances that have tyramine, such as red wine, meat, and aged cheese.
Substance P. Substance P is a brain chemical that is believed to have a role in mood disorders; agents that inhibit it have been found to have both antidepressant and antianxiety effects. In one investigative trial of patients with major depression, a substance-P blocker termed MK-869 was as effective as an SSRI and had similar side effects although less sexual dysfunction. It also reduced anxiety, independent of its effect on depression.
Augmentation strategies generally involve the use drugs not typically thought of as antidepressants in combination with an antidepressant. Such strategies are being used for patients who fail standard therapies or who need to quickly speed up the response of the antidepressant. Augmentation therapies include use of lithium, psychostimulants, thyroid hormones, beta-blockers, and anti-anxiety drugs. In one small study, high doses of thyroid hormone combined with an antidepressant had very mild side effects and were very effective in half of severely depressed treatment-resistant patients. Another study reported good results when thyroid hormone was followed by small doses of lithium. The anti-anxiety drug clonazepam (Klonopin) plus fluoxetine (Prozac) produced greater early improvement than Prozac alone in one study. Pindolol (Visken)a beta-blocker normally used for heart diseasewas effective against depression in another study when combined with the antianxiety drug buspirone (BuSpar). In another study, it was used with the SSRI paroxetine (Paxil) to hasten response. After ten days, depression in nearly half the patients taking the combination was in remission compared to 25% of patient taking Paxil only.
What Lifestyle Changes Can Help Depression?
Some people report relief from depression by eating foods or diet supplements that boost levels of tryptophan, an amino acid involved in the production of serotonin. Vitamin B3 (niacin) is important in the production of tryptophan and is produced from processing vitamin B3 (niacin). Dietary sources of niacin include oily fish (such as salmon or mackerel), pork, chicken, dried peas and beans, whole grains, seeds, and dried fortified cereals. The omega-3 polyunsaturated fatty acids found in fish oil may independently reduce depression. (There's no definite proof that any of these foods improve depression but, in any cases, they are all healthful.) A high-carbohydrate drink available over the counter called PMS Escape increases tryptophan level and may alleviate depression from PMS for about three hours. It should be strongly noted that impurities found in L-tryptophan diet supplements have been associated with eosinophilia-myalgia syndrome (EMS), a disorder that elevates certain white blood cells and causes muscle pain. An epidemic of EMS with some reported fatalities occurred in 1989; recently similar impurities have been detected in diet supplements containing 5-hydroxy-1-tryptophan (5HTP)a form of tryptophan.
Vitamin B12 and calcium supplements may help reduce depression that occurs before menstruation. Studies have found an association between drinking caffeinated beverages and a lower incidence of suicide, indicating that coffee or tea might help reduce depression.
Exercise may reduce mild to moderate depression and, in many cases, may be as effective as psychotherapy. Either brief periods of intense training or prolonged aerobic workouts can raise chemicals in the brain, such as endorphins, adrenaline, serotonin, and dopamine, that produce the so-called runner's high. One study found that teenagers who were active in sports have a greater sense of well being than their sedentary peers; the more vigorously they exercised, the better was their emotional health. Physical activity, particularly rhythmic aerobic and yoga exercises, helps combat stress and anxiety. And, of course, weight loss and increased muscle tone can boost self-esteem.
A strong network of social support is both important for prevention and recovery from depression. Support from family and friends must be healthy and positive; one study of depressed women showed, however, that overprotective as well as very distant parenting was associated with a slow recovery from depression. Studies indicate that people with strong spiritual faiths have a lower risk for depression. Such faith does not require an organized religion. People with depression might find solace from less structured sources, such as those that teach meditation or other methods for obtaining spiritual self-fulfillment.
Information obtained from Your Complete Well-Connected Guide To Depression http://www.well-connected.com