We all have the blues from time to time, but if you have depression (mate pāpouri), this feeling is stronger, it affects your thinking and behaviour, and lasts from weeks to months. However, no matter how low you feel, there is hope. There are people who can help you and things you can do to get on the road to recovery.
Key points about depression
Depression is very common and can affect anyone, at any age – from childhood through to old age. It’s not a sign of any kind of weakness or fault in you. About 1 in 6 people experience depression at some time in their life. It affects women more than men, but men seem less likely to recognise the problem and seek help.
Key symptoms include constantly feeling down or hopeless, loss of enjoyment or interest in doing the things you used to enjoy doing, negative thinking and sleep problems. You may feel so bad that you have thoughts of self-harm or even suicide.
Symptoms can range from mild to severe, and the support and treatment you need will depend on how severe your symptoms are.
Depression can usually be treated with a combination of psychological therapies, lifestyle changes and antidepressant medication.
If you’re depressed, it’s important to get help – the sooner you do, the sooner you'll start to feel better. Remember: there is hope. Many people have come out the other side of depression and have gone on to enjoy happy, healthy lives.
Image credit: 123rf
What are the symptoms of depression?
Depression is a change in mood, behaviour and feelings that can be mild, moderate or severe. Symptoms include:
low mood
frequently feeling sad and tearful
not wanting to socialise anymore
being unable to enjoy activities that once were fun
feeling stressed and anxious
poor appetite or overeating
physical symptoms such as pain (eg, headache, back pain)
tiredness and too much or too little sleep
difficulty concentrating and making decisions
not thinking straight
difficulty getting much done.
If your depression is more severe, you may also have thoughts of self-harm or suicide. If you have these thoughts, you should get help urgently from your doctor or one of the helplines listed on this page. There are people who can help you get through. Read more about severe depression.
What causes depression?
Sometimes depression appears out of the blue, while at other times something seems to trigger it. The exact cause of depression is unknown but many factors may play a role in depression. For example, you are more likely to experience depression if you:
have someone in your family who has been depressed, such as a parent or sibling
experienced trauma or abuse at an early age
have certain chronic physical health conditions, such as diabetes, cancer, heart disease, Parkinson’s diseaseor coeliac disease, or have had a stroke or have low thyroid hormone
are going through major life changes or have recently suffered a loss, such as a relationship break-up, redundancy, or a significant injury or accident
are LGBTI
are or have just been pregnant
are an older adult
use alcohol or recreational drugs
are taking certain medicines, such as for blood pressure or hormonal medication.
How is depression diagnosed?
If you are unsure whether you have depression, there are online self-tests you can do, including:
If you have some, but not necessarily all, the symptoms mentioned above, it’s a good idea to see your doctor. They will ask you questions about your thoughts, feelings and behaviour, including sleeping and eating patterns, as well as how long you have been feeling this way. They will also ask if you have had any previous episodes of depression and may ask about what is happening in your life at the moment. They may also do a physical examination and blood tests to rule out other causes for your depression.
Your doctor will be assessing not only if you have depression, but what type of depression and whether you have mild, moderate or severe symptoms, as this will affect what treatment they recommend.
What are the different types of depression?
There are several types of depression. You can still be depressed even if you don't meet all the criteria for one of these types. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) divides depression into the following categories:
Major depressive disorder – depression symptoms that interfere with your ability to work, sleep, study, eat and enjoy life. These may be mild, moderate or severe.
Persistent depressive disorder– a depressed mood that lasts for at least 2 years.
Premenstrual dysphoric disorder – a severe form of premenstrual syndrome experienced by some women before their periods.
Other depressive disorders – not meeting major depressive disorder criteria due to substance abuse, medication side effects, medical conditions, or other specified or unspecified reasons.
Other conditions also include symptoms of depression, such as the following:
Postpartum depression– a type of depression that some women experience after giving birth.
Depression can usually be effectively treated with a combination of psychological therapy, lifestyle changes and antidepressant medication. For Māori, an approach based on a Māori model of health has a more holistic understanding of wellbeing. For some people, alternative approaches have been useful, such as mindfulness meditation, St John's wort and online tools and courses. Find out more about treatment for depression.
What self-care can I do if I’m depressed?
Small steps are the key to change – choose what feels manageable and build from there.
Making your own self-care a priority builds your resilience so you can cope better with the challenges of life.
Looking after your physical health helps your mental wellbeing.
Having ways to reduce and manage stress increases your resilience.
Getting help when you need it is a sign of strength, not weakness.
Staying connected to family, whānau and friends can help you feel better.
Spending time in nature is key to your wellbeing.
Finding a purpose increases your sense of meaning and belonging.
The following links provide further information about depression. Be aware that websites from other countries may have information that differs from New Zealand recommendations.
Tina Earl is a clinical psychologist with over 20 years’ experience, currently in private practice and consultancy. She has been a clinical lead for psychological services in the DHB and primary care. Tina has authored resources at a national level for mental health clinical practice and service delivery, and is a subject matter consultant for psychological practice and mental health.
Credits: Health Navigator Editorial Team. Reviewed By: Tina Earl, Clinical psychologist
Last reviewed: 25 Feb 2019
There are several types of depression. You can still be depressed even if you don't meet all the criteria for one of these types. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) divides depression into the following categories:
Major depressive disorder– depression symptoms that interfere with your ability to work, sleep, study, eat and enjoy life. These may be mild, moderate orsevere.
Premenstrual dysphoric disorder – a severe form ofpremenstrual syndromeexperienced by some women before their periods.
Other depressive disorders – not meeting major depressive disorder criteria due to substance abuse, medication side effects, medical conditions, or other specified or unspecified reasons.
Other conditions also include symptoms of depression, such as the following:
Postpartum depression–a type of depression that some women experience after giving birth.
Bipolar disorder–different from depression, but includes episodes of extreme low moods as well as extreme high moods (mania).
Major depressive disorder
For a diagnosis of major depressive disorder, you will have experienced five or more of the following symptoms during the same 2-week period and this is a change from your previous functioning. At least one of your symptoms is either depressed mood or loss of interest or pleasure:
depressed mood most of the day, nearly every day, as self-reported or observed by others
diminished interest or pleasure in all or almost all activities most of the day, nearly every day
significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt nearly every day
diminished ability to think or concentrate nearly every day
recurrent thoughts of death, recurrent suicidal ideation without a specific plan.
In addition, these symptoms:
cause functional impairment (e.g., social, occupational)
are not better explained by substance abuse, medication side effects or other psychiatric or somatic medical conditions.
There are 3 levels of severity of major depression defined in the DSM-5:
Mild depression:Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment. Moderate depression: Symptoms or functional impairment are between mild and severe. Severe depression: Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms. Read more aboutsevere depression.
Persistent depressive disorder
For this diagnosis, you meet the above criteria for a major depressive disorder, or you have 3 or 4 of the following dysthymic symptoms including depressed mood, for 2 years or more. Your impairment compared with major depressive disorder may be less severe. Dysthymic symptoms are as follows:
If you have depression, especially if it is severe, it’s a good idea to have some form of face-to-face psychological (talking) therapy. Counselling or psychotherapy can help you with your thinking patterns and anxiety, problem-solving skills and self-esteem, among other things. Psychological therapy from a trained professional can help you recover and can reduce the chances of future bouts of depression. A number of psychotherapy approaches have been found to be helpful with depression, including cognitive behavioural therapy (CBT). You can ask your GP to recommend someone or find a counsellor yourself.
Lifestyle changes
Looking after your physical health is an important way to improve your mental health. Improvements to four aspects of your daily life can greatly reduce your depression: sleep, exercise, diet and the use of alcohol or other recreational drugs.
Sleep
Insomnia is closely associated with many mental illnesses, both as a symptom and a potential trigger. It co-occurs most commonly in major depression with around 80% of people diagnosed with depression experiencing insomnia.
Good sleep can improve your mood and also give you more resources for coping with life’s challenges. Find out about why sleep is important and check out these sleep tips or sleep apps. You could also try SHUTi, an evidence-based CBT programme for insomnia that has been shown to reduce depression (Note: there is a fee). If you are still having problems with your sleep, talk to your doctor about it.
Physical activity
People who are inactive are up to twice as likely to have depressive symptoms than active people. Even one hour of exercise a week has been found to prevent depression.
What we put into our bodies effects not only our physical health but also our mental wellbeing. A direct link has been found between diet and depression. Find out about healthy eating basics to make sure your diet is providing you with the nutrients to help keep depression at bay.
Alcohol and other recreational drugs
It’s important to avoid using alcohol and other drugs as these can often make depression worse. You may feel like they give you a lift in mood, but the overall effect is to make things worse. Read more about alcohol and mental health.
Antidepressant medications
Antidepressants are generally reserved for people with moderate to severe depression, where psychological therapy and lifestyle changes have not been enough for the depression to go away. They work best when used together with psychological therapy and lifestyle changes.
Antidepressants are not routinely used for people with mild depression because psychological therapy and lifestyle changes usually work well for mild symptoms. However, if your doctor recommends antidepressants, they will review with you regularly as to how well they are working, whether your dose needs adjusting or you need a different medication, and to work out when you are ready to start coming off them.
There are various classes of antidepressants. The most commonly used antidepressants for first-time treatment are selective serotonin re-uptake inhibitors (or SSRIs), such as citalopram, escitalopram, sertraline and fluoxetine. These work best when used together with psychological therapy and lifestyle changes. Most people will start noticing an improvement within 2 or 3 weeks but it will take 6 months or longer to get the full benefit. If you have troublesome side effects or little improvement in your symptoms after 6 weeks, talk to your doctor about changing the dose or trying a different antidepressant (switching).
It's normal to use antidepressants for up to a year, or longer if you have had depression before. Antidepressants are not addictive but coming off antidepressants should be done slowly, supervised by your doctor, to avoid withdrawal side effects. You should also talk to your doctor if you become pregnant or plan to become pregnant.
Also, check with your doctor or pharmacist before taking any other medicines or supplements – some have interactions with antidepressants that increase the risk of psychological and physical problems, even ones bought over the counter at a pharmacy and some herbal medicines.
For Māori, Western models of mental health and mental healthcare will not always be appropriate. An approach based on a Māori model of health has a more holistic understanding of wellbeing. For example, the four cornerstones (or sides) of Māori health in the Te Whare Tapa Whā model of health are:
whānau (family health)
tinana (physical health)
hinengaro (mental health)
wairua (spiritual health).
You can find a health practitioner who has a kaupapa Māori approach to wellbeing in this directory.
Alternative approaches
Certain complementary therapies may enhance your life and help you to maintain wellbeing. In general, mindfulness, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri massage and aromatherapy have all been shown to have some effect in alleviating mental distress.
Mindfulness
Mindfulness, the practice of being aware of each moment of your day as it happens, has been shown to be effective for some people with depression by helping to ease tension and promote calmness. You can learn how to do this from online courses such as Breathe or look for a group to go to in your area.
St John’s wort
Research has found that St John's wort is useful in the treatment of mild-to-moderate depression, but not effective in severe depression. The mechanism of action of St John’s wort is not fully understood but it is believed to affect certain chemicals in the body such as serotonin and noradrenaline, and, in this way, is thought to improve mood.
Many of the chemicals in St John's wort interact with medicines used to treat depression and other illnesses. It is important to let your doctor or pharmacist know if you want to try St John's wort so that they can check if it might interfere with other medicines you are taking.
Online tools and courses
For mild-to-moderate depression, online programmes can be useful and effective. Here are some well-researched programmes worth looking at:
The Journal – a free personalised online programme to help you to stay positive, create lifestyle changes, and learn steps for problem-solving.
Beating the Blues – an evidence-based online CBT tool for treating depression. Your doctor can provide access to this programme.
Small StepsWhether you’re looking to maintain wellbeing, find relief or get help, Small Steps can support you and your whānau with practical tools, strategies and advice.
SPARX – a free online tool to help young people learn to deal with depression and anxiety.
myCompass– an Australian interactive self-help service that aims to promote resilience and wellbeing for mild to moderate stress, anxiety and depression
MoodGYMand e-couch– cognitive behavioural therapy (CBT) based programmes from the Australian National University to help you identify and overcome problem emotions and develop good coping skills.
Aunty Dee – free online tool to help you work through problems.
Back from the bluez – an online course with strategies to help you manage your mood. Centre for Clinical Interventions, Australia,
Depression course – an evidence-based online course for if you have had more than one episode of depression (Note: this course has a fee). This Way Up, Australia
It's understandable that when you're depressed low energy, loss of pleasure and increased anxiety get in the way of doing the things you used to enjoy. However, taking small steps back to those things can help you to live well with depression – and may even be the start of the way out of it too.
Note: Some of these resources are from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116. Freephone or text 1737 to talk to a trained counsellor about your depression.
Note: This resource is from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116.
Note: This resource is from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116.
Note: This resource is from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116.
Note: This resource is from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116.
Note: This resource is from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116.
Note: This resource is from overseas so some details may be different in New Zealand, eg, phone 111 for emergencies or, if it’s not an emergency, freephone Healthline 0800 611 116.
Apps
There are a variety of mobile phone apps for anxiety, stress, depression and general mental health. They can help you learn about your condition, figure out whether your medication is working, record details about your symptoms or provide tools to help you manage mental health issues. The Health Navigator team has reviewed some mental health and wellbeing apps that you may like to consider.
Online self-help programmes and courses
Here are some online resources that are designed to help people manage depression and anxiety. Some are free, some have a cost and some require a prescription from your doctor.
Developed by the Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital and the University of New South Wales, Australia.
A range of self-assessment tests and courses on topics such as depression, generalised anxiety disorder, panic disorder, social phobia, OCD, health anxiety and PTSD.
Small StepsWhether you’re looking to maintain wellbeing, find relief or get help, Small Steps can support you and your whānau with practical tools, strategies and advice.
Concerns have been raised about the potential for antidepressants, particularly SSRIs, to cause suicidal thoughts and behaviour especially in adolescents and young adults. These concerns have prompted regulatory authorities in many countries to issue warnings. Australian and New Zealand Journal of Psychiatry 2015, Vol. 49(12) 1-185.
A consensus statement by the World Psychiatric Association (WPA) (Möller et al., 2008) concluded that in the absence of randomised controlled trial evidence, the risk is difficult to assess but that the available data indicated that there was a small risk of SSRIs inducing suicidal thoughts in patients up to the age of 25. The WPA advised that this risk needed to be balanced against the known benefits of treating depression and in preventing suicide. Clinicians should therefore advise young patients and their families of the small chance of suicidal thoughts emerging during the early phase of treatment with SSRIs and monitor all patients for the emergence or worsening of suicidal thoughts during the first 2–4weeks of treatment. The activation/agitation observed with the initial stages of taking an SSRI can be managed with a low dose of a benzodiazepine prescribed for a limited period of time. Clinical practice guidelines for mood disorders Royal Australian and New Zealand College of Psychiatrists, 2015
Systematic review 2018
A systematic review and network meta-analysis published in 2018 compared the efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder.
FINDINGS:
"We identified 28,552 citations and of these included 522 trials comprising 116,477 participants.
In terms of efficacy, all antidepressants were more effective than placebo, with ORs ranging between 2·13 (95% credible interval [CrI] 1·89-2·41) for amitriptyline and 1·37 (1·16-1·63) for reboxetine.
For acceptability, only agomelatine (OR 0·84, 95% CrI 0·72-0·97) and fluoxetine (0·88, 0·80-0·96) were associated with fewer dropouts than placebo, whereas clomipramine was worse than placebo (1·30, 1·01-1·68).
When all trials were considered, differences in ORs between antidepressants ranged from 1·15 to 1·55 for efficacy and from 0·64 to 0·83 for acceptability, with wide CrIs on most of the comparative analyses.
In head-to-head studies, agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants (range of ORs 1·19-1·96), whereas fluoxetine, fluvoxamine, reboxetine, and trazodone were the least efficacious drugs (0·51-0·84).
For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants (range of ORs 0·43-0·77), whereas amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine, trazodone, and venlafaxine had the highest dropout rates (1·30-2·32).
Risk of bias: 46 (9%) of 522 trials were rated as high risk of bias, 380 (73%) trials as moderate, and 96 (18%) as low; and the certainty of the evidence was moderate to very low."
INTERPRETATION:
"All antidepressants were more efficacious than placebo in adults with major depressive disorder. Smaller differences between active drugs were found when placebo-controlled trials were included in the analysis, whereas there was more variability in efficacy and acceptability in head-to-head trials. These results should serve evidence-based practice and inform patients, physicians, guideline developers, and policymakers on the relative merits of the different antidepressants." [1] Lancet, 2018
Access to the following regional pathways is localised for each region and access is limited to health providers. If you do not know the login details, contact your DHB or PHO for more information:
Improving treatments for depression - Pim Cuijpers (Goodfellow podcast, 2019) Pim Cuijpers talks about the challenge of improving treatments for depression. Pim is Professor of Clinical Psychology at the Vrije Universiteit Amsterdam (The Netherlands), and Head of the Department of Clinical, Neuro and Developmental Psychology. He is the world’s leading expert in the meta-analyses of reviews of psychotherapies.
Video series
Stress, anxiety and depression: new approaches to diagnosis and treatment
In this webinar, Professor Bruce Arroll looks at how we label patients with stress, anxiety, and depression by considering transdiagnostic labels. He will deal with the why and how, and highlight the dangers of labels in primary care.
(Goodfellow Unit Webinar, NZ, 2020)
Sensory modulation
In this series of 4 short videos, Karen Fraser explains what sensory modulation is and how it can be used to help clients modify their responses to stress and sympathetic drivers they encounter day to day.
Seminar series of 7 video updates about "non-drug therapies for common mental health conditions in primary care: depression, anxiety and distress. With the aim being to encourage practitioners to talk first, get patients being physically and socially active, and see how they do. With prescribing coming later, if and when needed" – from 13th April 2017.
Depression in primary care: The evidence base for first consultation Bruce Arroll
(Bruce Arroll, NZ, 2020)
References
Cipriani, A. Furukawa, A. Salanti, G. et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis Lancet. 2018 Feb 20.pii: S0140-6736(17)32802-7 [Full article]
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