Depression

What it's like

From the inside, the signs others notice, and the myths that keep people from help.

From the inside

• Empty, not just sad: A numb or empty feeling as often as a sad one.
• Nothing lands: Good things arrive and don't register — the brain's reward response is blunted.
• Bad news hits harder: Negative things land with more force, and the part of the brain that would put them in context responds less.
• Slowed down: Tired, heavy, everything an effort.
• Foggy: Hard to concentrate, remember or decide.
• Worthless: Guilt, worthlessness and hopelessness that feel like facts, not moods.

Everyone has low days. Depression is different in how long it lasts and how much it takes over: a depressed mood or a loss of interest or pleasure, most of the day, nearly every day, for at least two weeks.

Common signs

• Mood: A sad, anxious or "empty" feeling that doesn't lift.
• Hope: Feeling hopeless or pessimistic.
• Temper: Irritability, frustration or restlessness.
• Self-worth: Guilt, worthlessness or helplessness.
• Pleasure: Losing interest in hobbies and things that used to be enjoyable.
• Energy: Tiredness, or feeling slowed down.
• Thinking: Trouble concentrating, remembering or making decisions.
• Sleep: Sleeping badly, waking too early, or sleeping too much.
• Appetite: Eating more or less, or weight changing without trying.
• Body: Aches, headaches or stomach problems with no clear physical cause.
• Death: Thoughts of death or suicide.

In children and teenagers

Younger children may be anxious or cranky, pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent will die. Older children and teenagers may get into trouble at school, be easily frustrated and feel worthless — and are more likely to sleep and eat more, not less.

Depression also shows up as behaviour: more anger, more risk-taking, more alcohol or drugs, pulling away from family and friends, and letting responsibilities slide. Women are diagnosed more often, but men are more likely to go undiagnosed and untreated.

• Myth: It's just sadness. They should snap out of it. In fact: Depression changes how the brain responds to bad news and to reward. Nobody chooses that, and it's a condition with treatments that work.
• Myth: Depression is a chemical imbalance — too little serotonin. In fact: The main lines of research give no consistent evidence that low serotonin causes depression. Antidepressants do help — researchers think by gradually changing how emotional information is processed and how the brain adapts, rather than by topping up a missing chemical.
• Myth: Antidepressants are happy pills that work straight away. In fact: They usually take 4–8 weeks to have their effect. The delay is one of the reasons scientists don't think they work simply by adding a chemical.
• Myth: Asking someone about suicide might put the idea in their head. In fact: Studies have found no increase in suicidal thoughts when people are asked about them — talking about it may even reduce them.
• Myth: If it runs in the family, it's inevitable. In fact: Close relatives of someone with depression have nearly three times the odds of it, and genes account for about 37% of the risk. Most of the rest is each person's own life experience.
• Myth: Once you've had it, it'll keep coming back. In fact: In the general population, about two in three people who recover don't have another episode in the next 15 years.

What's happening in the brain

Bad news lands harder, good news lands softer, and the part that could argue back goes quiet. The model lights each one as you read.

Depression isn't one broken part. Brain imaging shows several systems responding differently — to bad news and to good news. Together they explain why it feels the way it does.

The alarm, turned up

Shown negative images, people with depression respond more strongly in the amygdala, the insula and the dorsal anterior cingulate. Bad news lands harder, and seems to mean more.

The voice of reason, turned down

At the same time, the dorsolateral prefrontal cortex — the part that would normally put a negative thought in context — responds less. The researchers' reading is that negative information isn't reaching the part of the brain that could reappraise it. That's why "look on the bright side" doesn't work: the machinery for doing it is the part that's quiet.

Reward, muted

Across 38 imaging studies, the striatum responded less when a reward arrived — and in teenagers, that blunting could come before depression began. This is the loss of pleasure: things that used to feel good arrive, and don't land.

Memory under strain

In nearly 9,000 people, the hippocampus was about 1% smaller on average in depression — driven by depression that kept coming back or began by age 21. A first episode showed no difference.

A target for new treatments

A small area under the front of the cingulate, the subgenual cingulate, is overactive in depression. When it was quietened by deep brain stimulation — an experimental treatment — four of six people whose depression had resisted everything else went into lasting remission.

Most antidepressants act on chemical messengers like serotonin, but mood takes weeks to lift — far longer than the chemical change takes. The leading explanations are that they first shift how emotional information is processed, and over time help the brain's circuits adapt.

Why it happens

Some genes, a lot of life — and rarely one single cause.

• 37% heritability: How much of the risk of depression comes from genes, in twin studies. The rest is mostly each person's own experience.
• 1.5× as common in women: About 6.2% of women and 4.1% of men have depression.
• 10%+ around birth: Over 10% of women who are pregnant or have just given birth experience depression.

Genetic, biological, environmental and psychological factors all play a part. Depression runs in families, but what families share in their home life explains almost none of it; what matters beyond genes is what happens to each person individually.

It often comes with long-term physical illness — diabetes, cancer, heart disease and chronic pain. Both the WHO and the US National Institute of Mental Health advise cutting down on alcohol and avoiding drugs as part of getting better.

Getting a diagnosis

How depression is recognised, and the first steps if you're worried.

Depression is diagnosed from the symptoms and how long they've lasted — most of the day, nearly every day, for at least two weeks. In the US, the American Academy of Pediatrics recommends that every young person aged 12 and over is screened for depression at their yearly check-up.

If you're worried about someone

• Say what you've noticed: Plainly and without blame: "You've seemed really low lately, and I'm worried about you."
• Listen more than you talk: You don't need to fix it in the first conversation.
• Suggest a doctor: A family doctor is the usual first step. For a teenager, offer to make the appointment and to go with them.
• Write it down: What you've seen, since when, and what it's affecting — sleep, school, work, friends.
• Ask about suicide: Directly, if you're at all worried. It's covered in "When to get help" below.

What helps

Talking therapy, medication, both, and what you can do alongside them.

What the WHO recommends

• Mild depression: Talking therapy; antidepressants aren't needed.
• Moderate or severe: Talking therapy, which can be combined with an antidepressant.
• Children: Antidepressants shouldn't be used to treat depression.
• Teenagers: Antidepressants aren't the first choice, and need extra caution.

• Talking therapy (Cognitive behavioural therapy, behavioural activation, interpersonal therapy, problem-solving therapy.): The WHO's first-line treatment for depression. For adults, therapy works about as well as medication, and people are more likely to stick with it.
• Antidepressants (Usually an SSRI, such as fluoxetine or sertraline, taken daily.): In 522 trials with more than 116,000 adults, all 21 antidepressants studied worked better than placebo. They usually take 4–8 weeks, so the first weeks aren't a verdict — and starting or stopping should always go through the prescriber. People under 25 can have more suicidal thoughts early in treatment or after a dose change — in trials, about 2 more in every 100 young people than on placebo — so that's when to watch closely.
• Both together (Therapy and medication at the same time.): For adults with moderate depression, combining the two worked better than either on its own.
• Exercise (Walking or jogging, yoga, strength training.): Across 218 trials, each gave moderate reductions in depression, more at higher intensity — but most trials had weaknesses, so the certainty is low. It's a sensible addition to treatment, and part of the self-care both the WHO and NIMH recommend.

Getting better is the usual outcome. In the general population, about two in three people who recover don't have another episode in the next 15 years — and the biggest risks of it coming back are the number of past episodes and symptoms that never fully cleared. That's why it's worth treating depression until it's gone, not just until it's better.

Supporting someone

What to say, what to do, and what to do if it's you.

• Instead of "Cheer up — other people have it much worse.", try "You've seemed really low lately. I'm here, and I want to understand.". Guilt and worthlessness are symptoms of depression. A comparison adds to them rather than lifting anything.
• Instead of "You just need to get out more.", try "Want to come for a walk with me? Just twenty minutes.". An invitation works where an instruction doesn't — and inviting someone out is one of the things that helps.
• Instead of "You're not thinking of doing anything stupid, are you?", try "Are you thinking about suicide?". Ask directly, in plain words. It opens the conversation, and it doesn't put the idea there.
• Instead of "Let's not dwell on it.", try "Thank you for telling me. Let's work out the next step together.". Listening, then helping them connect to support, is what makes the difference.

Helping someone day to day

• Offer support, understanding, patience and encouragement.
• Invite them out — walks, outings — and keep inviting even when they say no.
• Help them stick with treatment, and get them to appointments.
• Remind them that with time and treatment, depression lifts.
• Look after yourself. Supporting someone through depression is tiring, and you'll help more if you're not running on empty.

If it's you

• Keep doing things you used to enjoy, even when you don't feel like it.
• Stay in touch with friends and family.
• Move — even a short walk counts.
• Keep regular times for sleeping and eating.
• Cut down on alcohol, and avoid drugs.
• Put off big decisions until you feel better.
• Talk to someone you trust, and to a doctor.

When to get help

The warning signs of suicide, and exactly what to do.

Warning signs of suicide

• Talking about wanting to die, or to kill themselves.
• Looking for a way — searching online, getting hold of pills or a weapon.
• Talking about feeling hopeless, trapped, in unbearable pain, or a burden to others.
• Drinking or using drugs more.
• Acting anxious, agitated or reckless.
• Sleeping too little or too much.
• Withdrawing from people.
• Rage, talk of revenge, or extreme mood swings.

What makes them matter most

Warning signs matter most when they're new, getting worse, or follow a painful event, loss or change.

What to do

1. Ask: Ask directly whether they're thinking about suicide. Listen, and pay attention to their own reasons for living.
2. Be there: In person or on the phone — and only promise what you can actually do.
3. Keep them safe: Find out if they have a plan, and put distance between them and the means — medicines, weapons.
4. Help them connect: To a crisis line, a doctor or a mental health professional, and to a written safety plan.
5. Follow up: Check in afterwards — a call, a text — and do what you said you'd do.

If someone is in immediate danger

If they have a plan and the means, or have already hurt themselves, call your emergency number now and stay with them until help arrives.

Put it into practice

Five real situations. Choose what you'd do, and see why.

• For about a month your 15-year-old has been snapping at everyone. They've quit football, which they loved, and sleep until noon at weekends. Asked, they say they're "fine, just tired". What's most likely going on? It could be depression — worth a calm conversation and a doctor's appointment. In teenagers, depression often shows as irritability, frustration and sleeping more. Signs lasting two weeks or more are the line worth acting on.
• A friend says, quietly, "Everyone would be better off without me." What do you do? Ask them directly whether they're thinking about suicide, and listen. Talking about being a burden is a warning sign. Asking directly opens the conversation and doesn't put the idea there.
• Your partner started an antidepressant two weeks ago. They feel no different, and say they'll stop taking it. What's the best response? Encourage them to talk to their doctor before changing anything. It's usually 4–8 weeks before they work, and starting or stopping should go through the prescriber.
• You're 19 and have just started an antidepressant. Two weeks in, you're sleeping badly and having darker thoughts than before. What should you do? Tell your doctor straight away, and someone you trust. People under 25 can have more suicidal thoughts early in treatment — in trials, about 2 more in every 100 than on placebo — and that's exactly when to speak up.
• Someone tells you depression is just low serotonin, so an antidepressant is simply fixing a deficiency. Is that right? Antidepressants help, but probably not by topping up a missing chemical. They work better than placebo, but their effect takes weeks, and researchers think they gradually change how emotion is processed and how the brain adapts.