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What causes depression?

Onset of depression more complex than a brain chemical imbalance.

It's often said that depression results from a chemical imbalance, but that figure of speech doesn't capture how complex the disease is. Research suggests that depression doesn't spring from simply having too much or too little of certain brain chemicals. Rather, there are many possible causes of depression, including faulty mood regulation by the brain, genetic vulnerability, and stressful life events. It's believed that several of these forces interact to bring on depression.

To be sure, chemicals are involved in this process, but it is not a simple matter of one chemical being too low and another too high. Rather, many chemicals are involved, working both inside and outside nerve cells. There are millions, even billions, of chemical reactions that make up the dynamic system that is responsible for your mood, perceptions, and how you experience life.

With this level of complexity, you can see how two people might have similar symptoms of depression, but the problem on the inside, and therefore what treatments will work best, may be entirely different.

Scientists have learned much about the biology of depression, but their understanding of the biology of depression is far from complete. Major advances in the biology of depression include finding links between specific parts of the brain and depression effects, discovering how chemicals called neurotransmitters make communication between brains cells possible , and learning the impact of genetics and lifestyle events on risk and symptoms of depression .

This article will address the how different parts of the brain affect mood.

Brain regions and mood

Popular lore has it that emotions reside in the heart. Science, though, tracks the seat of your emotions to the brain. Certain areas of the brain help regulate mood. Researchers believe that — more important than levels of specific brain chemicals — nerve cell connections, nerve cell growth, and the functioning of nerve circuits have a major impact on depression.

Increasingly sophisticated forms of brain imaging — such as positron emission tomography (PET), single-photon emission computed tomography (SPECT), and functional magnetic resonance imaging (fMRI) — permit a much closer look at the working brain than was possible in the past. An fMRI scan, for example, can track changes that take place when a region of the brain responds during various tasks. A PET or SPECT scan can map the brain by measuring the distribution and density of neurotransmitter receptors in certain areas.

Use of this technology has led to a better understanding of which brain regions regulate mood and how other functions, such as memory, may be affected by depression. Areas that play a significant role in depression are the amygdala, the thalamus, and the hippocampus (see Figure 1).

Research shows that the hippocampus is smaller in some depressed people. For example, in one fMRI study published in  The Journal of Neuroscience , investigators studied 24 women who had a history of depression. On average, the hippocampus was 9% to 13% smaller in depressed women compared with those who were not depressed. The more bouts of depression a woman had, the smaller the hippocampus. Stress, which plays a role in depression, may be a key factor here, since experts believe stress can suppress the production of new neurons (nerve cells) in the hippocampus.

Researchers are exploring possible links between sluggish production of new neurons in the hippocampus and low moods. An interesting fact about  antidepressants  supports this theory. These medications immediately boost the concentration of chemical messengers in the brain (neurotransmitters). Yet people typically don't begin to feel better for several weeks or longer. Experts have long wondered why, if depression were primarily the result of low levels of neurotransmitters, people don't feel better as soon as levels of neurotransmitters increase.

The answer may be that mood only improves as nerves grow and form new connections, a process that takes weeks. In fact, animal studies have shown that antidepressants do spur the growth and enhanced branching of nerve cells in the hippocampus. So, the theory holds, the real value of these medications may be in generating new neurons (a process called neurogenesis), strengthening nerve cell connections, and improving the exchange of information between nerve circuits. If that's the case, depression medications could be developed that specifically promote neurogenesis, with the hope that patients would see quicker results than with current treatments.

Figure 1:   Areas of the brain involved with depression

The regions shown here are mirrored in both hemispheres of the brain. Also, these structures are interlocking; the illustration suggests relative position but not precise location.

Amygdala:  The amygdala is part of a group of structures deep in the brain that’s associated with emotions such as anger, pleasure, sorrow, fear, and sexual arousal. Recalling an emotionally charged memory, such as a frightening situation, activates the amygdala. Activity in the amygdala is higher when a person is sad or clinically depressed, and this continues even after recovery from depression. This increase in activity may actually cause the amygdala to enlarge.

Basal ganglia (not pictured):  The basal ganglia are a related group of structures deep in the brain. They are connected to and interact with structures that are closer to the brain’s surface. They may help facilitate movement and may be involved in memorizing, thinking, and emotional processing. Some studies have found shrinkage and other structural changes in the basal ganglia in people with depression.

Hippocampus:  The hippocampus plays a key role in processing long-term memory. Interplay between the hippocampus and the amygdala might account for the adage "once bitten, twice shy." It is this part of the brain that registers fear when you are confronted by a barking, aggressive dog, and the memory of such an experience may make you wary of dogs you come across later in life. The hippocampus is smaller in some depressed people, and research suggests that ongoing exposure to stress hormones impairs the growth of neurons in this part of the brain.

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Understanding Depression

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What is depression and why is it rising?

It’s an illness that fills our news pages on an almost daily basis. Juliette Jowit asks what causes depression, who is susceptible and what the best treatment is

What is depression?

Depressed people don’t all shuffle around with a long face, or cry at any provocation. MentalHealth.gov , a US government website, defines it as “losing interest in important parts of life”. Symptoms include eating or sleeping too much or too little; pulling away from people and usual activities; having low or no energy; feeling numb or like nothing matters; feeling unusually confused, forgetful, on edge, angry, upset, worried or scared; and thinking of harming yourself or others.

A visceral description is quoted by the UK campaign group Mind : “It starts as sadness, then I feel myself shutting down, becoming less capable of coping. Eventually, I just feel numb and empty.”

Depression is also often mixed with other health problems: long-term illness, anxiety, obsessive compulsive disorder or schizophrenia, for example.

The term dysthymia is also used for mild, long-term depression – usually lasting two years or more.

How many people have depression?

Clinical depression has surged to epidemic proportions in recent decades, from little-mentioned misery at the margins of society to a phenomenon that is rarely far from the news. It is widespread in classrooms and boardrooms, refugee camps and inner cities, farms and suburbs.

At any one time it is estimated that more than 300 million people have depression – about 4% of the world’s population when the figures were published by the World Health Organization (WHO) in 2015. Women are more likely to be depressed than men.

Depression is the leading global disability, and unipolar (as opposed to bipolar) depression is the 10th leading cause of early death, it calculates. The link between suicide, the second leading cause of death for young people aged 15-29, and depression is clear, and around the world two people kill themselves every minute.

While rates for depression and other common mental health conditions vary considerably, the US is the “most depressed” country in the world, followed closely by Colombia, Ukraine, the Netherlands and France. At the other end of the scale are Japan, Nigeria and China.

Why are there such wide variations?

The stark contrasts between countries have led some to dub depression as a “first world problem” or a “luxury”. The logic is that if you are staring down the barrel of a gun or you don’t know where the next meal is coming from, you have no time for such introspection.

Recent research points to myriad reasons, many overlapping: in particular less developed countries often lack the infrastructure to collect data on depression, and are less likely to recognise it as an illness. Also, people in these countries are more likely to feel a social stigma against talking about how they feel, and are reluctant to ask for professional help.

Statistics are also less simplistic than rich = depressed and poor = not depressed.

A paper in the journal Plos Medicine argues that, extremes aside, the majority of countries have similar rates of depression. It also found that the most depressed regions are eastern Europe, and north Africa and the Middle East; and that, by country, the highest rate of years lost to disability for depression is in Afghanistan, and the lowest in Japan.

What causes depression?

Things have improved since people with mental illness were believed to be possessed by the devil and cast out of their communities, or hanged as witches. But there remains a widespread misunderstanding of the illness, particularly the persistent trope that people with depression should just “buck up”, or “get out more”.

A contrasting opinion is provided by the psychiatrist Dr Tim Cantopher’s book Depressive Illness: The Curse of the Strong.

He argues there is a part of the brain called the limbic system that acts like a thermostat, controlling various functions of the body – including mood – and restoring equilibrium after the normal ups and downs of life. The limbic system is a circuit of nerves, transmitting signals to each other via two chemicals, serotonin and noradrenalin, of which people with depression have a deficit. According to this description, depressive illness is predominantly a physical, not mental, illness.

Cantopher says that, when under stress, weak or lazy people give in quickly; strong people keep going, redouble their efforts, fight any pressure to give up and so push the limbic system to breaking point. However, there is no scientific evidence to support this theory, as it is impossible to experiment on live brains.

Other commonly agreed causes or triggers are past trauma or abuse; a genetic predisposition to depression, which may or may not be the same as a family history; life stresses, including financial problems or bereavement; chronic pain or illness; and taking drugs, including cannabis, ecstasy and heroin.

The subject of much debate, there is a school of thought that severe stress or certain illnesses can trigger an excessive response from the immune system, causing inflammation in the brain, which in turn causes depression.

The WHO estimates that fewer than half of people with depression are receiving treatment. Many more will be getting inadequate help, often focused on medication, with too little investment in talking therapies, which are regarded as a crucial ally.

Among pharmacological treatments for depression, the most commonly prescribed antidepressants are selective serotonin re-uptake inhibitors (SSRIs) which reduce the absorption of serotonin, increasing overall levels. Another popular class of drugs is serotonin norepinephrine re-uptake inhibitor (SNRIs), which work on both serotonin and noradrenaline.

The most common talking therapy is cognitive behavioural therapy, which breaks down overwhelming problems into situations, thoughts, emotions, physical feelings and actions to try to break a cycle of negative thoughts.

Other types are interpersonal therapy, behavioural activation, psychodynamic psychotherapy and couples therapy. All talking therapies can be used on their own, or with medication.

Away from the medical approach, doctors can prescribe physical activity or arts therapy, while some patients opt for alternative or complementary therapies, most popularly St John’s Wort herbal pills, mindfulness and yoga.

While there are more and more treatments for depression, the problem is rising, not falling.

From 2005-15, cases of depressive illness increased by nearly a fifth. People born after 1945 are 10 times more likely to have depression. This reflects both population growth and a proportional increase in the rate of depression among the most at-risk ages, the WHO said.

Suicide rates, however, have declined globally, by about a quarter. In 1990, the rate was 14.55 per 100,000 people, in 2016 the rate was 11.16 per 100,000.

A key reason for the continuing rise in depressive illness is that drugs do not necessarily “cure” the patient, and other therapies that can make the crucial difference are usually not in sufficient supply.

Other reasons given for the continuing rise in depressive illness include an ageing population (60- to 74-year-olds are more likely to suffer than other age groups), and rising stress and isolation.

No new antidepressant drugs have been developed in the last 25 years, forcing psychiatrists to look elsewhere for help.

There have been positive experiments with both ketamine and psilocybin , the active ingredient in magic mushrooms. Further hopes for a new generation of treatments have been raised by recent discoveries of 44 gene variants that scientists believe raise the risk of depression. Another controversial area of research is treatment for low immunity and mooted links between depression and inflammation.

Countries are increasingly recognising the need to train more psychologists to replace or complement drug treatments.

And perhaps most importantly, there is a cultural movement to make it easier for people to ask for help and speak out about their illness.

Some of the most visible leaders of this shift are the UK’s princes William and Harry, who set up the charity Heads Together and have talked publicly about their own problems. Others are celebrities; most recently the wrestler and actor Dwayne “The Rock” Johnson has spoken about his depression, and the singer Mariah Carey has talked about having bipolar disorder.

Further reading

Personal stories of depression from mental health charity Mind

World Health Organisation report

MentalHealth.gov , for wider information on mental health

Country and regional statistics from Plos Medicine Journal

All Kinds of Minds TED Talks

Tim Cantopher: Depressive Illness, the Curse Of the Strong

• The briefing
• Mental health
• World Health Organization

Most viewed

What Is Depression?

Reviewed by Psychology Today Staff

"The grey drizzle of horror," author William Styron memorably called depression. The mood disorder may descend seemingly out of the blue, or it may come on the heels of a defeat or personal loss, producing persistent feelings of sadness, worthlessness, hopelessness, helplessness, pessimism , or guilt . Depression also interferes with concentration , motivation , and other aspects of everyday functioning.

According to the World Health Organization, depression is the leading cause of disability worldwide. Globally, more than 300 million people of all ages suffer from the disorder. And the incidence of the disorder is increasing everywhere. Americans are highly concerned with happiness , yet they are increasingly depressed: Some 15 million Americans battle the disorder, and increasing numbers of them are young people.

Depression comes in forms ranging from major depression to dysthymia and seasonal affective disorder. Depressive episodes are also a feature of bipolar disorder .

Depression is a complex condition, involving many systems of the body, including the immune system, either as cause or effect. It disrupts sleep and it interferes with appetite ; in some cases, it causes weight loss; in others, it contributes to weight gain. Depression is also often accompanied by anxiety . Research indicates that not only do the two conditions co-occur but that they overlap in vulnerability patterns.

Because of its complexity, a full understanding of depression has been elusive. There is mounting evidence that depression may actually be a necessary defense strategy of the body, a kind of shutdown or immobilization in response to danger or defeat , that is actually meant to preserve your energy and help you survive.

Researchers have some evidence that depression susceptibility is related to diet , both directly—through inadequate consumption of nutrients such as omega-3 fats—and indirectly, through the variety of bacteria that populate the gut. But depression involves mood and thoughts as well as the body, and it causes pain for both those living with the disorder and those who care about them. Depression is also increasingly common in children.

Even in the most severe cases, depression is highly treatable. The condition is often cyclical, and early treatment may prevent or forestall recurrent episodes. Many studies show that the most effective treatment is cognitive behavioral therapy , which addresses problematic thought patterns, with or without the use of antidepressant drugs. In addition, evidence is quickly accumulating that regular mindfulness meditation , on its own or combined with cognitive therapy , can stop depression before it starts by diminishing reactivity to distressing experiences, effectively enabling disengagement of attention from the repetitive negative thoughts that often set the downward spiral of mood in motion.

For more on causes, symptoms, and treatments of depressive disorders, see our Diagnosis Dictionary .

What Are the Signs of Depression?

Not everyone who is depressed experiences every symptom. Some people experience a few symptoms, some many. The severity of symptoms varies among individuals and over time.

Depression often involves persistent sad, anxious , or empty mood; feelings of hopelessness or pessimism ; and feelings of guilt , worthlessness, or helplessness. It can also involve loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex . Decreased energy, fatigue, or a sense of being "slowed down" are also common, as are restlessness, irritability, and difficulty concentrating, remembering, or making decisions. Many with depression have thoughts of death or suicide.

People with depression may experience disruptions in sleep ( insomnia , early morning awakening or oversleeping) and in eating behavior ( appetite changes, weight loss or gain). Persistent physical symptoms may include headaches, digestive disorders, and chronic pain .

For more see Signs and Symptoms of Depression.

What Causes Depression?

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biologic, environmental, and psychological factors. Major negative experiences— trauma , loss of a loved one, a difficult relationship, or any stressful situation that overwhelms the ability to cope—may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

Depression is not an inevitable consequence of negative life events, however. Research increasingly suggests that it is only when such events set in motion excessive rumination and negative thought patterns, especially about oneself, that mood enters a downward spiral.

Research utilizing brain-imaging technologies such as magnetic resonance imaging (MRI) shows that the brains of people who have depression look different than those of people who do not. Specifically, the parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. It is not clear which changes seen in the brain may be the cause of depression and which may be the effect.

Some types of depression tend to run in families, suggesting there may be some genetic vulnerability to the disorder.

For more see Causes of Depression .

How Is Depression Treated?

Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier treatment begins, the more effective it can be and the greater the likelihood that recurrence can be prevented.

Appropriate treatment for depression starts with an examination by a physician. Certain medications, as well as some medical conditions such as viral infections or a thyroid disorder, can cause the same symptoms as depression and should be ruled out. The doctor should ask about alcohol and drug use, and whether the patient has thoughts about death or suicide.

Once diagnosed, a person with depression can be treated a number of ways. The most common treatments are medication and psychotherapy . Many studies show that cognitive behavioral psychotherapy is highly effective, alone or in combination with drug therapy.

Psychotherapy addresses the thinking patterns that precipitate depression, and studies show that it prevents recurrence. Drug therapy is often helpful in relieving symptoms, such as severe anxiety, so that people can engage in meaningful psychotherapy.

For more see Treatment of Depression and Therapy for Depression .

Natural Approaches to Depression

Depression requires active treatment, because the disorder can have enduring effects on brain function that make future episodes more likely. The longer a depression episode lasts, the more likely a future episode.

However, there are many ways to treat depression, and some of the most effective, especially in cases of mild to moderate disorder, do not require a prescription or medical-type intervention of any kind.

Depression can be seen as a kind of cave , and it takes some time and effort to get out of the cave. But it is possible, usually by learning some new patterns of thinking and doing. Nutrition plays a role as well.

For more see Natural Approaches to Depression.

Depression and Your Health

Mental anguish is hard on your health: People suffering from depression have three times the risk of experiencing a cardiac event. In fact, depression affects the entire body. It weakens the immune system, increasing susceptibility to viral infections and, over time, possibly even some kinds of cancer—a strong argument for early treatment. It also interferes with sleep, adding to feelings of lethargy, compounding problems of focus and concentration , and generally undermining health.

Those suffering from depression also experience higher rates of diabetes and osteoporosis. Sometimes depression manifests as a persistent low mood, a condition known as dysthymia which is usually marked by years-long periods of low energy, low self-esteem , and little ability to experience pleasure.

For more see Depression and Physical Health .

Living with Depression

Everyone experiences an occasional blue mood. Yet clinical depression is a more pervasive experience of repetitive negative rumination, bleak outlook, and lack of energy. It is not a sign of personal weakness or a condition that can be willed or wished away. People with depression cannot merely "pull themselves together" to get better.

It doesn't help that modern-day living carries growing pressures. There is an emphasis on early childhood achievement at the expense of free play, a cultural shift away from direct social contact in favor of electronic connection, and a focus on material wealth at the expense of rich experiences and social contact. All play a part.

However, there is some evidence that, painful as depression is, it may serve a positive purpose, bringing with it ways of thinking that force those who suffer to focus on problems as a prelude to solving them. In effect, some researchers hypothesize that depression can help prod a person into much needed self-awareness.

For more see How to Prevent and Manage Depression .

The Major Forms of Depression

What most people mean when they talk about depression is unipolar depression—an unremitting state of sadness, apathy, hopelessness, and loss of energy. It is also called major depression.

Depressive episodes also occur in bipolar disorder , a condition marked by periods of depression interspersed with periods of high-energy mania . People swing between the two poles of mood states, sometimes over the course of days, and sometimes over years, often with stable periods in between.

The birth of a baby can trigger mood swings or crying spells in the days or weeks that follow, the so-called baby blues. When the reaction is more severe and prolonged, it is considered postpartum depression , a condition requiring treatment because it can interfere with a parent's ability to care for their newborn.

Depression can also occur seasonally, primarily in the winter months when sunlight is in short supply. Known as seasonal affective disorder, or SAD, it is often ameliorated by daily exposure to specific types of artificial light.

For more see Types of Depression .

The Biology of Depression

Depression makes deep inroads on biology to bring about the many symptoms of depression, from sleep disruption and inability to experience pleasure to lack of motivation and feelings of guilt. Because of its complexity—and because the disorder contributes so much to human suffering—the biology of depression is a major subject of ongoing research.

Overexcitability of the stress response system, shifts in activity of various neurochemicals in the brain, diminished efficiency of nerve circuitry and nerve generation, disturbances in energy use in nerve cells, the intrusion of inflammatory substances in the brain, upsets in the brain’s 24-hour (circadian) clock—all play a role in depression onset or progression and influence the kind and severity of symptoms.

For more see The Biology of Depression

Depression and Suicide

Most suicides are linked to some form of psychiatric illness, particularly depression, and the more severe the depression, the greater the risk. Still, most people with major depression do not die by their own hand.

Studies show that about 5 percent of depressed persons may have thoughts about suicide— suicidal ideation. Only a small percentage of them actively make plans to end their lives.

The clearest warning sign of suicide is talk about wanting to die . And the best way to determine whether suicide is a risk is to ask.

For more see Depression and Suicide .

Children and Depression

Mental health conditions such as depression are increasingly afflicting the young, including preschoolers. Especially in the young, depression requires active treatment—it can interfere with normal development.

Depression can show up in children much as it does in adults, signified by sadness, lethargy, and disinterest. But especially among children it manifests as irritability. Other times it manifests as anger and acting out.

Depression in children can have many causes. It can be a response to bullying . There is ample evidence that social media plays a role in depression among young people. Another source may be the decline of free play, an arena in which children traditionally work out their concerns and a great source of pleasure.

For more see Children and Depression .

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All About Depression

Depression is one of the most common mental health conditions, affecting approximately 280 million people worldwide.

A sense of hopelessness, the feeling of being “weighed down,” and a loss of enjoyment in things that used to bring you joy — these are some common signs of depression, one of the most widespread mental health issues in the world.

Clinical depression goes by many names, such as “the blues,” biological or clinical depression, and major depressive disorder (MDD). The World Health Organization (WHO) estimates that approximately 280 million people live with depression.

Even simple things — like getting dressed in the morning or eating at mealtime — can feel like large obstacles when you have depression.

Depression symptoms take many forms, and no two people’s experiences are exactly alike. A person with depression may not always seem sad to others. And when friends or family do notice signs of depression, they may want to help but not know how.

What is depression?

The National Institute of Mental Health (NIMH) estimates that about 7% of U.S. adults experience depression each year.

Clinical depression is different from sadness or grief — like when you lose a loved one, experience a relationship breakup, or get laid off from work — as it usually consumes you in your day-to-day living.

Unlike sadness, depression doesn’t stop after only a day or two. It can continue for weeks on end, interfering with your work or school, relationships with others, and ability to enjoy life.

Some people feel as if a huge hole of emptiness has opened inside when experiencing the hopelessness associated with depression. Apathy and anhedonia, or inability to feel pleasure, are common aspects of depression.

Depression symptoms and diagnosis

You’ll likely speak with a mental health professional such as a psychologist, psychiatrist, or clinical social worker, who could diagnose your condition.

Though a general practitioner or family doctor can make an initial diagnosis, a specialist can provide complete follow-up and treatment.

If you’ve experienced most of the following symptoms every day over 2 or more weeks, you might meet the criteria for a depression diagnosis:

• a persistent feeling of loneliness or sadness
• lack of energy
• feelings of hopelessness
• getting too much or too little sleep
• eating too much or too little
• difficulties with concentration or attention
• loss of interest in enjoyable activities or socializing
• feelings of guilt and worthlessness
• thoughts of death or suicide

Depression can look very different from person to person , and the intensity of the symptoms may also vary. Also, if you have depression, you might not experience every symptom.

Depression can appear differently in children than in adults. Some symptoms in children can include anxiety or anxious behavior.

Wondering if what you’re experiencing might be depression? You can check out our depression test to find out.

Learn more about symptoms of depression.

Types of depression

While MDD is the main diagnosis associated with depression, there are also other kinds of depression. Each form of depression has its own set of symptoms.

Major depressive disorder (MDD)

MDD is what comes to mind for most people when they think of depression. It’s also the most common depression diagnosis.

If you experience a loss of pleasure in activities you used to enjoy, along with a depressed mood that lasts at least 2 weeks, you might meet the criteria for MDD. In children and teens, MDD can also look like irritability rather than sadness.

Postpartum depression

Postpartum depression is depression that can occur in people who have just given birth. It can also occur in other parents and caregivers who haven’t given birth.

Typically, postpartum depression can begin in the first month after giving birth, but it can also begin during pregnancy. If you have a history of depression, you may be more likely to experience postpartum depression.

Seasonal affective disorder

Seasonal affective disorder is a subtype of depression triggered by seasonal changes. Though it’s more common in the winter and fall months, it can occur in the summer as well.

If you notice persistent sadness or lack of energy during a certain time of year, you might have seasonal depression. Treatment includes light therapy, establishing consistent sleep routines, and talk therapy.

Persistent depressive disorder (dysthymia)

Persistent depressive disorder (PDD) , previously known as dysthymia and chronic major depression, is a form of depression that lasts for at least 2 years.

While it can be more challenging to treat than other types of depression, it’s possible to get relief from symptoms. If you’re diagnosed with PDD, you’ll likely work with your healthcare professional to create a treatment strategy that’s best suited for you.

Bipolar disorder depression

Some forms of bipolar disorder involve depressive episodes . Sometimes depressive episodes alternate with episodes of mania or hypomania.

Treatment for bipolar disorder depression can differ from other depression treatment approaches. For example, due to the nature of bipolar disorder, antidepressants are not always a safe way to manage bipolar disorder symptoms.

Other depression subtypes

Other subtypes of depression include depression with the following:

• melancholic

If you talk with a therapist, you might learn if any of these specifiers apply to you. You can also learn more about the types of depression below.

Learn more about depression types.

Depression risk factors and causes

As with most mental health conditions, researchers still aren’t sure what causes depression. But most experts consider the following to be contributing factors:

• gut bacteria
• family history
• personality
• environment
• social factors and upbringing

Anyone can experience the effects of depression . But some risk factors indicate how likely you are to experience it.

For instance, women might be 2 to 3 times as likely as men to develop depression.

According to the NIMH , other risk factors for depression can include:

• a family history of mood disorders
• major life changes
• trauma or chronic stress
• medical conditions
• certain medications
• alcohol or other substance use

Even if you don’t identify with any depression risk factors, you could still meet the criteria for a depression diagnosis. You can learn more about the causes and risk factors for depression below.

Learn more about risk factors and causes of depression.

Depression treatment

Can depression actually be successfully treated? The short answer is yes.

According to the NIMH and countless research studies over the past 6 decades, clinical depression is readily treated with short-term, goal-oriented psychotherapy or talk therapy and antidepressant medications .

For most people, a combination of the two works best and is often recommended by healthcare professionals.

Psychotherapy

Psychotherapy approaches scientifically proven to work with depression include:

• cognitive behavioral therapy (CBT)
• interpersonal therapy
• psychodynamic therapy

Therapy is one of the most effective treatments for all types of depression, and it has very few side effects. It’s also typically covered by all insurers.

Self-help strategies

For mild depression, many people begin with self-help strategies and emotional support. Research also indicates some herbal remedies, including St. John’s wort and saffron, may help relieve certain depression symptoms.

Exercise and diet are other factors to consider when building a routine to manage depression. Though it can be difficult to practice consistent self-care habits when experiencing a depressive episode, small steps can help.

Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed medications for depression.

When psychotherapy and antidepressants don’t work, clinicians may consider other treatment options. Usually, additional medication to support the existing antidepressant medication is considered.

Additional treatment options such as electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS) may be tried in more serious cases.

Effective treatment depends on recognizing there’s a problem, seeking to address it, and following a treatment plan. This can be challenging when you have depression, but patience is key when beginning treatment.

No matter how hopeless things may feel, you can get better with treatment — many people do.

You can learn more about the benefits of psychotherapy and medications and whether you should consider one or both in our in-depth depression treatment guide below.

Learn more about your depression treatment options.

Living with depression

If you live with depression, simply waking up in the morning and getting out of bed can feel like a struggle.

Everyday tasks — like showering, eating, or going to work or school — can sometimes feel like large hurdles to a person living with depression.

One key to managing living with depression is ensuring you’re receiving treatment or taking steps to build a solid self-care routine. Treatment could include therapy, medication, or both.

Also, being an active participant in your own wellness plan can be helpful. While this can require effort, it can be done. For some people with depression, leaning on a support network or trusted loved one can help.

Establishing self-care routines is important in managing depression. Getting regular emotional support — for instance, through an online support group — can also be beneficial.

Learn more about living with depression.

Helping someone with depression

When you see a family member or friend experiencing an episode of depression, it’s normal to want to reach out and lend a hand. But when it comes to depression, what you can do to help isn’t always clear.

Loved ones of a person with depression may remain silent, fearful of making the situation worse or alienating the person they care about. And while more people are becoming aware of depression and its effects, stigma tied to the condition persists and prevents people from discussing it.

If you think a loved one could be experiencing a depressive episode, there are ways you can offer support.

Below are some articles that offer guidance for people who want to learn how they can best support a loved one who has depression.

Helping a loved one with depression:

• How Can I Help Someone in My Life Who’s Depressed?
• 9 Best Ways to Support Someone with Depression
• 9 Ways to Help a Friend or Family Member with Depression
• 4 Ways to Support Someone with Depression
• Identifying Depression in the Elderly

What to say to someone with depression:

• 10 Things You Should Say to a Depressed Loved One
• 6 Things to Say to Someone with Depression or Who’s Depressed
• What Not to Say to a Depressed Person
• Worst Things to Say to Someone Who’s Depressed

Helping a partner with depression:

• Recognizing Depression in Your Partner
• How to Help Your Partner Through Their Depression
• Suffering in Silence: When Your Spouse Is Depressed
• Depression: The Spouse’s Side of the Story
• When a Depressed Spouse Refuses Help

Helping a child or teen with depression:

• Signs of Childhood Depression
• Depression in Teens and Children
• 7 Common Mistakes Parents Make When Trying to Help Their Depressed Teen
• Is My Teenager Depressed or Just Moody? 8 Questions to Consider Before Getting Help
• 4 Facts About Teen Depression and How Parents Can Help

Recovery from depression can take time, but there is hope. There are many steps you can take to manage depression.

You can begin by talking with someone — anyone — about your feelings and finding some immediate emotional support through the sharing.

Some people begin by talking with their family physician. A medical professional can also offer referrals or encourage you to continue your treatment with a mental health specialist.

When it comes to managing depression, your first step can connect you with the resources you need to manage your symptoms and thrive.

Suicide prevention

Remember that you’re not alone and resources are available to you. If you need to talk to someone right away, you can:

• Call the National Suicide Prevention Lifeline 24 hours a day at 800-273-8255.
• Text “HOME” to the Crisis Textline at 741741.

Not in the U.S.? You can find a helpline in your country with Befrienders Worldwide .

Last medically reviewed on February 16, 2021

6 sources collapsed

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.
• Depression. (2020). who.int/news-room/fact-sheets/detail/depression
• Depression basics. (2016). nimh.nih.gov/health/publications/depression/index.shtml
• Labonté B, et al. (2017). Sex-specific transcriptional signatures in human depression. ncbi.nlm.nih.gov/pmc/articles/PMC5734943/
• Major depression. (2019). nimh.nih.gov/health/statistics/major-depression.shtml
• Sarris J. (2018). Herbal medicines in the treatment of psychiatric disorders: 10-year updated review. pubmed.ncbi.nlm.nih.gov/29575228/
• What Causes Depression?
• Treating Depression: What Are My Options?
• Coping with Depression: A Resource Guide
• What Are the Symptoms of Major Depression?
• Introduction to Depression

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My Depression in My Life

Depression is something that shows itself differently for everyone. There is no one person, or one story, or one experience that can make someone universally understand truly how depression alters the lives of those of us who suffer from it. I can’t make anyone understand how it is for everyone, but I can tell you how it alters my life, and maybe that will help people understand how all-encompassing it really is.

For me there are two main ways that my depression manifests itself when it breaks through the barriers I have set with the help of years of therapy and medication. There is the gut wrenching loneliness and near constant anxiety and then there is the checking out, the feeling nothing at all, the numbness. Sometimes I don’t know which is worse, but I will try to explain both.

The Loneliness and Anxiety:

In some ways I consider this step one of when my depression spikes because it always seems to come first. But I don’t consider it step one in levels of horribleness. Like I said above I really think that both ways my depression hits me are pretty awful and I couldn’t say which is worse.

You know that feeling you have in your gut when you are about to and/or really need to cry. While that is what it is like. All the time. I could be laughing and having a great time with my friends, which I often am because my friends are great, and yet in the back of my mind I feel more alone than ever and I just want to curl up into fetal position and cry. But I never can. I can’t go home and cry and then feel better, because it’s not like there is something to cry about, or really anything to be sad about. And it isn’t really sadness. It is complete solitude. It’s when my brain tells me that I am alone, that I can’t be loved, that no one really wants me around, and worst of all that no one will understand me.

That is worst of all because at the place I am in my life, no matter what I have been through in the past, or what my depression tries to make me believe I know that I can be loved, that I’m not alone and that I am wanted. And I know that because of the hard work I have done to get to that place in my life, and because of some of the amazing people in my life who make sure that I know that they are there for me, that they love me, and that they want to spend time with me.

But the idea that no one will ever truly understand who I am, or any of that. That is a little harder to dissuade myself from believing. Because as much as I can tell people what I went, and still go through and what goes through my mind, who can really understand me other than me. And that isn’t necessarily a bad thing, but the way my depression tells me it, it is a bad thing.

So there I am surrounded by people, very possibly having some of the best experiences of my life, feeling like I need to bawl, completely unable to, and nearly having an anxiety attack because I just want it to end.

And it is here where two things happen. It is here where I wish for and welcome the numbness because I don’t want to feel the all-encompassing loneliness and anxiety. It is also where I think about cutting.

I have not cut myself in three and a half years. And I know that it doesn’t solve my problems. I know that I shouldn’t and I don’t want to. Even when I want to I don’t want to.

But here, when I am feeling the all-encompassing loneliness which is the very last thing that I want to feel, I think about cutting because it lets me feel something else.

The physical act of cutting gives me something to think about and focus on, something other than that loneliness. And when I am not physically cutting, instead of thinking about how lonely I am and how that feeling will never end I think about the next time I can cut, or the most recent time I did.

And Then The Numbness:

I don’t really know how to explain this numbness. It is simply a period of time where I feel literally nothing. I fake happiness/normal emotion around friends, not always very well, and when I am alone I just don’t care about anything.

This is when my grades often fall because I don’t care about anything, including school, and therefore school work.

And then, sometimes I just want to feel something, anything, and so that is when I think about cutting. I think about cutting because it gives me something to feel, something I can control, but still feel.

The numbness comes because I can’t handle what I’m thinking and feeling, because it is too much for me to deal with, so I shut everything off so I don’t have to feel it.

In some ways, cutting transitions me back into feeling. But again, cutting, NOT A SOLUTION, NOT HEALTHY.

And something that I no longer do.

Now, for the past three and a half years, whenever I think of cutting, which I still do. It is still my first thought in either of these situations, I instead do one of the many things that I have come to know to help me cope.

For example, I force myself to spend more time with my friends, because I know that the loneliness will pass and I can talk myself out of feeling lonely when I am not physically alone.

I read/watch anything romantic. I pretend that I am one of the characters, and then I feel what they feel instead of what I am feeling (or preventing myself from feeling).

I belt along to old school Taylor Swift. Because what is more beautiful than a summer romance in a small country town with Chevy trucks and Tim McGraw?

And though my schoolwork does still sometimes fall through the cracks, I always make myself do some work.

Basically I force myself to live my life, because well, it is my life, and I refuse to live it feeling alone when I’m not, and numb when I could be great.

So even though I do feel those things far more often than I would like it is something that I live with, because I have depression.

Because depression is a disease, and I will always have it.

Because my depression is a part of who I am.

And most of all, because I only have one life, and I want to live it. Because even though when my depression spikes it makes me want to not live sometimes, I refuse.

Because I am the author of my own life and I choose to put a semicolon instead of a period at every point that my depression tells me otherwise.

So that is how my depression affects my life. That is how I deal with it. Like it or not I always will.

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Course: US history   >   Unit 7

• The presidency of Herbert Hoover

The Great Depression

• FDR and the Great Depression
• The New Deal
• The Great Depression was the worst economic downturn in US history. It began in 1929 and did not abate until the end of the 1930s.
• The stock market crash of October 1929 signaled the beginning of the Great Depression. By 1933, unemployment was at 25 percent and more than 5,000 banks had gone out of business.
• Although President Herbert Hoover attempted to spark growth in the economy through measures like the Reconstruction Finance Corporation, these measures did little to solve the crisis.
• Franklin Roosevelt was elected president in November 1932. Inaugurated as president in March 1933, Roosevelt’s New Deal offered a new approach to the Great Depression.

The stock market crash of 1929

Hoover's response to the crisis, what do you think, want to join the conversation.

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I Had It All, So Why Was I So Depressed?

By Carola Lovering

It started with a couple of sleepless nights after getting home from a friend’s wedding in Florida. The weekend had been a whirlwind and I was exhausted, but I couldn’t fall asleep. In their rooms across the hall, my toddler and my four-month-old both slept soundly—miraculously—and this only exacerbated the anxiety coursing through my veins. The babies were asleep and I wasn’t. What was wrong with me? There’d be a hellish price to pay in the morning.

This happened two nights in a row—anxiety that came out of nowhere and left me nocturnal, pacing the kitchen at 3 a.m. while the backs of my eyelids burned with fatigue. I’d been awake for 48 hours. I was on deadline for a new book but doing my job on no sleep was out of the question; I put whatever scraps of energy I had into getting through the days with the kids. I googled  what happens if you just stop sleeping forever  and plunged down a Reddit rabbit hole, terrifying myself with descriptions of hallucinations and delirium.

I considered that what was manifesting itself as anxiety might actually be a slide back into the depression I’ve managed for much of my life. The worst kinds of pain are like that; they dwell in you, buried some place inaccessible, deeper than memory. As with labor contractions, you forget until you don’t.

Depression—the grisly intruder that turns my own mind into a frightening place—had snuck up on me again, like the late November sunset. A cottony sky turned suddenly black, the daylight extinguished, night encroached. It was only 4:26 in the afternoon, but I looked out our kitchen window to darkness, shadowy outlines of skeletal trees that filled me with a sense of impending doom.

My son wanted a veggie burger for dinner so I tossed one on the cast iron pan and listened to it thaw, olive oil crackling like the nerves on the back of my neck. I should’ve been hungry, too, but my stomach sank. Zero appetite.

I opened Spotify and selected Van Morrison’s top tracks, hoping the familiar music would lift me. But it only made me feel worse, Van’s voice a cruel reminder that it wasn’t summer, that it would never be summer again.

Wine, maybe. I chose a bottle of Malbec and poured myself a glass, just enough to relax, to get me to sleep that night. But a single sip made me dizzy and edgy, guilt-ridden when I remembered the early hour. Four twenty-nine. The minutes crawled by like sludge.

I crafted a text to my parents, hit send without thinking about it.

I haven’t been sleeping and I feel so anxious and low. And it’s so dark outside. So scary and ominous. I hate November.

The feelings of dread continued to brew as I waited for a reply. How long had I been taking for granted the fact that my parents were there, that I could tell them anything and know they would rush to my aid? All at once I was hit with the inevitability of losing them, a non-negotiable fact that sat heavy on my chest, a sickening weight.

My father, who has depression, too, texted back. He sent a quote from Albert Camus, a screenshot of an old poem.  In the midst of winter, I found there was, within me, an invincible summer.

But it wasn’t even winter yet. It was only the lead-up, short days becoming shorter and shorter, a slow descent into lightlessness. 

My dad sent another text, as if reading my mind.  Light is coming. Light is coming.

Then, one more.  You need to talk to Roger. ASAP. Let me know when you do.

Roger is my psychiatrist, the same one I’ve had for 13 years. I remember the first day I walked into his office, an ashamed and afraid 21-year-old, so thin my pants kept slipping. The appointment had been scheduled by my parents, who were worried about me, but I hadn’t put up a fight. It was weird to be in therapy, or so I thought back then, but I was worried about me, too. Roger told me it was depression; he detected it on my face right away. In the hunch of my shoulders and the lack of intonation in my voice.  You have a brain chemistry imbalance , he said, but I didn’t fully believe that. It was only when I started taking Prozac and felt the dark weight lift that I began to understand he was onto something, that the ominous existence I’d been experiencing wasn’t  me . 

And yet: Through my twenties and earlier thirties there was a subliminal part of me that continued to suspect that my depression—or anyone’s depression—was circumstantial. Sure, there were good days and bad days, and I’d probably always feel a bit low leading up to the winter solstice—doesn’t everybody?—but when my life reached a point of steady happiness, so would I. That was when depression would cease to rear its ugly head, forevermore.

Thirteen years after that initial diagnosis, how could I be back here? How could I possibly be depressed? My life dazzled with living dreams: two beautiful babies, a marriage that was happy if not a bit rocked by the demands of young parenthood, a novel that had just been adapted into a Hulu series , and a new two-book deal on top of that. My own luck was stupid, the kind that provokes imposter syndrome.

When my husband walked in the door later that evening, I told him it had been another bad day, that my mental health was in crisis. He took the kids so I could disappear into my office, where I typed out a message to Roger. I wrote that I was having a really tough time, that I’d lost my appetite and hadn’t been able to sleep, that I’d been harboring unfounded worries about loved ones dying and was so tired my eyes felt like they were made of sand. Could we talk?

We scheduled a FaceTime session for the following morning.

“Could it be  postpartum depression?” I asked when he confirmed what I already knew deep down—that my depression had returned.

By Janelle Okwodu

By Christian Allaire

“Maybe.” Roger said something specific and medical about hormones at four months postpartum . “So it could be PPD. But you have a history with this regardless, and this time of year is hard for you, so we know what needs to be done. Let’s come up with a plan.”

The relief I felt in that moment was palpable. If there’s one lesson I’ve gleaned thus far in my life—one piece of wisdom I could choose to impart on my children—it’s the transformative power of learning to ask for help.

Roger and my plan involved a vitamin D supplement, a renewed commitment to cardiovascular exercise, daily use of my Happy Light, and an increased dose of my antidepressant, which had been lowered during my pregnancy. 

It was all of these remedies combined with my belief in their healing powers—a belief almost equal to certainty—that is, perhaps, what sped up my recovery. A placebo effect that helped me ride out the weeks until my serotonin levels replenished, like scorched grass drinking up rain.

In January, I felt a wave of relief for a new year. Or maybe it was knowing that the planet had begun its tilt toward the sun, that a little more light would pour over the earth each day until June 21, my birthday.  Maybe that’s why I’m fucked in the winter , I thought.  I’m a summer solstice baby; I was born into maximum vitamin D.

I met my deadline. I bought a monthly pass to a yoga studio and vowed to go, even if it meant cutting into the hours I paid for childcare, time I was normally strict about designating for work . I lay in savasana, soaked through with sweat in the 95-degree room; I blinked up at the square of blue through the skylight, overcome with the feeling that it would all be okay, that it already was. 

Several months later I’m back to myself, depression in the rearview again. But now, as I march through life—as I write and edit and parent and soak up fleeting moments with my rapidly-growing children—I carry this: the warning that depression doesn’t give a shit how happy you are. Depression doesn’t discriminate. It can look like rock bottom but it can also appear the way I did in November, a woman capping off a year of highs. I now have a better sense of this discrepancy, which of course plays out in any number of ways among the 280 million people affected by depression worldwide .

The clocks were set back on a Sunday in March, and the following evening I took a 6 p.m. yoga class. When I left the studio just after seven, it was still light outside, the air filled with something I can only describe as the promise of spring. As I drove home, my body and mind humming with endorphins, I thought of what my father said to me back in November.  Light is coming . As it turns out, he was right.

May is Mental Health Awareness month. If you or someone you know is in crisis, please call 988 or reach out to the national Suicide & Crisis Lifeline , which provides free and confidential support.

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How Miserable Are We Supposed to Be?

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By Huw Green

Dr. Green is a clinical psychologist.

In my work as a psychologist for people dealing with the aftermath of significant injuries, I am often presented with the question of whether low mood in my patients is best understood as a normal reaction to a serious health event — it’s reasonable, for instance, to respond to news that you may never walk again with questions about how life might be different and more challenging — or as clinical depression that should be treated. This is an extremely difficult determination to make.

Part of the reason it is so hard is that there are serious disagreements about where to draw the line between the two and even whether it can be drawn at all. Psychiatry’s guiding paradigm is that some extremes of mood are sufficiently severe that they constitute illness. But a longstanding criticism of psychiatry claims that the issues it professes to treat are just ordinary aspects of the human condition (or “problems in living,” as the psychiatrist Thomas Szasz, a staunch critic of his own profession, would have it) that are being unnecessarily pathologized. This argument isn’t restricted to questions about diagnoses; a version of it plays out across multiple mental-health-related debates. At first glance, these can look like separate discussions, but they tend to boil down to the same central questions: Is happiness always the goal of mental health treatment? How can we know when we’re happy enough? How miserable are we supposed to be?

This debate is perhaps at its fiercest when it involves discussions around psychiatric medication. The generation of antidepressants that were introduced in the 1980s were initially hailed as miracle drugs that could help patients feel, as one psychiatrist put it, “ better than well ,” improving their personalities and resolving depression. In time, however, concerns developed that such medications blunted people’s moods or numbed them. Today clinicians and researchers argue interminably about the minutiae of whether antidepressants really address a brain chemistry issue or they work by dampening emotions . Are we treating people who need help or sedating them through the highs and lows of life?

Emotions run particularly high around medication, and the same questions arise in the field of psychotherapy. The intervention being debated in this case is slower moving, but clinicians still disagree about the fundamental purpose of the talking cure.

For those operating in the tradition of cognitive behavioral therapy, the goal is something like symptom reduction. Moods can be measured and, with the right approach — by adjusting distorted patterns of thinking, for instance — improved.

Existential and psychodynamic approaches to psychotherapy frame things differently, placing understanding and meaning making at the center. Freud provided a sense of the mission early on with his comment that the goal of psychoanalysis is to transform symptoms into “ordinary human misery.” The psychologist George Prigatano, in his book about the psychological treatment of neuropsychological disorders, baldly states (quoting Charlie Chaplin) that “the theme of life is conflict and pain.”

The basic fault line that runs through various mental health controversies has to do with the role of misery in our lives. Misery is inevitable, but we also have a sense that there can sometimes be too much of it. We don’t want to eliminate misery; that seems somehow morally dubious and practically impossible. But nonetheless, it sometimes strikes us that we could be happier than we are. One way of dealing with this problem is to think in terms of illness — and, certainly, misery can become so profound that it starts to resemble an illness.

Pinning down the broader tensions in these disputes can help explain what we’re really arguing about. Because these discussions often happen among clinicians and scientists and because they often take place in peer-reviewed journals, they have the appearance of technical debates. The hope appears to be that, with enough care, we could land on a successful definition of mental disorder, the correct psychotherapeutic protocol or set of guidelines for prescribing. This hope is misguided. When we argue about definitions, therapy and medicines, we are often arguing about something more significant and overarching.

How miserable are we supposed to be? It is extremely difficult to know when low mood trips over into depression or when people’s thoughts about their lives are distortions. When does emotional dysregulation become mania? When do idiosyncrasy and magical thinking become psychosis? This difficulty is what leads us to outsource such determinations to clinicians and other assorted experts. Those experts are then imbued with significant power. They assess and diagnose us and reflect for us a view of how maladjusted we are. Concerns about this power have made mental health such a fraught topic. We want clinicians to have some power, but we worry about it.

But the power to make determinations about when we are ill and what constitutes too much distress is actually a power that still resides, to a great extent, with the general public rather than specialists. Psychiatrists have tried in various ways to develop a definition of mental disorder. These can be based on statistical notions of normality or on theories of mental dysfunction that are grounded in what is considered natural. Such definitions fall down, though, as pointed out by the philosopher Derek Bolton, because statistical rarity by itself does not entail aberration. And determining mental dysfunction is impossible, given that it’s apparently hard to agree on how our minds ought to function: Are we supposed to go through periods of intense, crippling sadness, or are we not?

Dr. Bolton resolved this by deciding it was impossible to ground our notion of disorder in any set of biological or statistical facts. Mental disorder, he concluded, is more or less whatever a community decides it is. If you start behaving in ways that are uninterpretable by your community, you might find yourself in front of a psychiatrist. The extent to which we are mentally unhealthy is a function of what starts to seem unhealthy in the context of people who know us well and are trying to get along with us. As the psychoanalyst John Rickman succinctly put it, “Madness is when you can’t find anyone who can stand you.”

To navigate the question of who should be referred to treatment for their misery, I need to be guided by medical definitions of depression. These definitions are what we’ve used to test the efficacy of treatments, and they translate our idiosyncratic preferences as clinicians into the professional standards of our peers. If patients seem sad but still basically engaged with life, I might aim to support them in navigating their experience of loss and change through therapy. If their low moods are persistent across several weeks and they are consistently hopeless, with disrupted sleep, guilt and negative thoughts, I might refer them to a psychiatrist to consider medication.

My thinking about this process has changed. Earlier in my career, I was concerned about missing “true” cases of depression. Now I take a more pragmatic attitude. If I refer patients to a psychiatrist, it is not that I think the underlying fact of the matter is that they are depressed. Rather, I am aware that some people are able to benefit from antidepressants — that their lives can plausibly be made better — and that my patients, because they resemble other such individuals, may be such people.

When I ask myself some version of “Are these people more miserable than they’re supposed to be?” my clinical judgment comes to resemble something more commonplace than a medical diagnosis. Not detached from the standards set by my professional peers but now more grounded in practical considerations about the intelligibility of a person’s feelings, rather than abstract technical notions of pathology and treatability.

The value of this reframing is that it has a sort of democratizing power. It gives more weight to people’s priorities and their life contexts alongside the definitions created to guide expert diagnosis. I am not deciding that they are depressed; we are deciding together, alongside the community at large, that the misery has become too much to bear.

Huw Green ( @Huwtube ) is a clinical psychologist specializing in neuropsychology.

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Depression in Teens

It’s not unusual for young people to experience "the blues" or feel "down in the dumps" occasionally. Adolescence is always an unsettling time, with the many physical, emotional, psychological and social changes that accompany this stage of life.

Unrealistic academic, social, or family expectations can create a strong sense of rejection and can lead to deep disappointment. When things go wrong at school or at home, teens often overreact. Many young people feel that life is not fair or that things "never go their way." They feel "stressed out" and confused. To make matters worse, teens are bombarded by conflicting messages from parents, friends and society. Today’s teens see more of what life has to offer — both good and bad — on television, at school, in magazines and on the Internet. They are also forced to learn about the threat of AIDS, even if they are not sexually active or using drugs.

Teens need adult guidance more than ever to understand all the emotional and physical changes they are experiencing. When teens’ moods disrupt their ability to function on a day-to-day basis, it may indicate a serious emotional or mental disorder that needs attention — adolescent depression. Parents or caregivers must take action.

Dealing With Adolescent Pressures

When teens feel down, there are ways they can cope with these feelings to avoid serious depression. All of these suggestions help develop a sense of acceptance and belonging that is so important to adolescents.

• Try to make new friends. Healthy relationships with peers are central to teens’ self-esteem and provide an important social outlet.
• Participate in sports, job, school activities or hobbies. Staying busy helps teens focus on positive activities rather than negative feelings or behaviors.
• Join organizations that offer programs for young people. Special programs geared to the needs of adolescents help develop additional interests.
• Ask a trusted adult for help. When problems are too much to handle alone, teens should not be afraid to ask for help.

But sometimes, despite everyone’s best efforts, teens become depressed. Many factors can contribute to depression. Studies show that some depressed people have too much or too little of certain brain chemicals. Also, a family history of depression may increase the risk for developing depression. Other factors that can contribute to depression are difficult life events (such as death or divorce), side-effects from some medications and negative thought patterns.

Recognizing Adolescent Depression

Adolescent depression is increasing at an alarming rate. Recent surveys indicate that as many as one in five teens suffers from clinical depression. This is a serious problem that calls for prompt, appropriate treatment. Depression can take several forms, including bipolar disorder (formally called manic-depression), which is a condition that alternates between periods of euphoria and depression.

Depression can be difficult to diagnose in teens because adults may expect teens to act moody. Also, adolescents do not always understand or express their feelings very well. They may not be aware of the symptoms of depression and may not seek help.

These symptoms may indicate depression, particularly when they last for more than two weeks:

• Poor performance in school
• Withdrawal from friends and activities
• Sadness and hopelessness
• Lack of enthusiasm, energy or motivation
• Anger and rage
• Overreaction to criticism
• Feelings of being unable to satisfy ideals
• Poor self-esteem or guilt
• Indecision, lack of concentration or forgetfulness
• Restlessness and agitation
• Changes in eating or sleeping patterns
• Substance abuse
• Problems with authority
• Suicidal thoughts or actions

A quick, easy and confidential way to determine if you may be experiencing depression is to take a mental health screening. A screening is not a diagnosis, but a way of understanding if your symptoms are having enough of an impact that you should seek help from a doctor or other professional. Visit  www.mhascreening.org  to take a depression screening.

Teens may experiment with drugs or alcohol or become sexually promiscuous to avoid feelings of depression. Teens also may express their depression through hostile, aggressive, risk-taking behavior. But such behaviors only lead to new problems, deeper levels of depression and destroyed relationships with friends, family, law enforcement or school officials.

Treating Adolescent Depression

It is extremely important that depressed teens receive prompt, professional treatment.

Depression is serious and, if left untreated, can worsen to the point of becoming life-threatening. If depressed teens refuse treatment, it may be necessary for family members or other concerned adults to seek professional advice.

Therapy can help teens understand why they are depressed and learn how to cope with stressful situations. Depending on the situation, treatment may consist of individual, group or family counseling. Medications that can be prescribed by a psychiatrist may be necessary to help teens feel better.

Some of the most common and effective ways to treat depression in adolescents are:

• Psychotherapy provides teens an opportunity to explore events and feelings that are painful or troubling to them. Psychotherapy also teaches them coping skills.
• Cognitive-behavioral therapy helps teens change negative patterns of thinking and behaving.
• Interpersonal therapy focuses on how to develop healthier relationships at home and at school.
• Medication relieves some symptoms of depression and is often prescribed along with therapy.

When depressed adolescents recognize the need for help, they have taken a major step toward recovery. However, remember that few adolescents seek help on their own. They may need encouragement from their friends and support from concerned adults to seek help and follow treatment recommendations.

Facing the Danger Of Teen Suicide

Sometimes teens feel so depressed that they consider ending their lives. Each year, almost 5,000 young people, ages 15 to 24, kill themselves. The rate of suicide for this age group has nearly tripled since 1960, making it the third leading cause of death in adolescents and the second leading cause of death among college-age youth.

Studies show that suicide attempts among young people may be based on long-standing problems triggered by a specific event. Suicidal adolescents may view a temporary situation as a permanent condition. Feelings of anger and resentment combined with exaggerated guilt can lead to impulsive, self-destructive acts.

Recognizing the Warning Signs

Four out of five teens who attempt suicide have given clear warnings. Pay attention to these warning signs:

• Suicide threats, direct and indirect
• Obsession with death
• Poems, essays and drawings that refer to death
• Giving away belongings
• Dramatic change in personality or appearance
• Irrational, bizarre behavior
• Overwhelming sense of guilt, shame or rejection
• Changed eating or sleeping patterns
• Severe drop in school performance

REMEMBER!!! These warning signs should be taken seriously. Obtain help immediately. Caring and support can save a young life.

Helping Suicidal Teens

• Offer help and listen . Encourage depressed teens to talk about their feelings. Listen, don’t lecture.
• Trust your instincts. If it seems that the situation may be serious, seek prompt help. Break a confidence if necessary, in order to save a life.
• Pay attention to talk about suicide. Ask direct questions and don’t be afraid of frank discussions. Silence is deadly!
• Seek professional help. It is essential to seek expert advice from a mental health professional who has experience helping depressed teens. Also, alert key adults in the teen’s life — family, friends and teachers.

Looking To The Future

When adolescents are depressed, they have a tough time believing that their outlook can improve. But professional treatment can have a dramatic impact on their lives. It can put them back on track and bring them hope for the future.

If you or someone you know is contemplating suicide, call 1-800-273-TALK (1-800-273-8255).

Other Resources

The Boys Town National Hotline. (800)-448-3000 .

Suicide Awareness/Voices of Prevention

The Jed Foundation . Suicide prevention for college students.

The Nine Line . (800) 999-9999. Covenant House crisis counseling for homeless and at-risk children.

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What Does Depression Feel Like?

• Identify Your Emotions
• Cope With Your Emotions
• When You Feel Lonely
• When You Feel Emotional
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• When You Feel Irritable
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• When You Feel Helpless
• When You Feel Hopeless

Sara Lindberg, M.Ed., is a freelance writer focusing on mental health, fitness, nutrition, and parenting. 

Carly Snyder, MD is a reproductive and perinatal psychiatrist who combines traditional psychiatry with integrative medicine-based treatments.

Verywell / Laura Porter

What Depression May Feel Like

• According to People With Depression
• Types of Depression
• Common Signs and Symptoms
• Tips for Friends and Family
• Next in Small Ways to Feel Better When You're Depressed Guide How to Identify Your Emotions When You’re Depressed

Sadness is something we all experience from time to time. For some, this feeling is temporary and goes away on its own. But for others, this persistent feeling of emptiness, unhappiness, and hopelessness becomes a regular part of their day.

If your mood has changed over the last few weeks and engaging in routine daily tasks is getting more difficult, you may have depression , and you're not alone.

Depression is one of the most common mental health disorders in the United States. According to data from 2017, it is estimated that 17.3 million adults aged 18 or older in the United States had a least one major depressive episode in the past year.

Depression, a mood disorder that can cause mild to severe symptoms , can affect how you feel, think, and manage daily activities.

Many people believe that depression needs to be debilitating and cause significant problems in their life in order to seek help. What they don’t realize is that some of the more subtle signs of this disorder are often the first indication that something is going on. Here are some examples of how depression may feel to you.

• Depression feels like there is no pleasure or joy in life. According to Anjani Amladi , MD, a board-certified psychiatrist, it’s so much more than being sad. According to Amladi, “depression robs people of things they once loved, and for many people, they feel like nothing will bring them joy again.” 
• Concentration and focus become much more difficult, which makes any kind of decision-making challenging. Amladi says that sometimes people describe this as being in a fog as they are unable to think clearly or follow what is happening around them.
• For many with depression, it feels like there is no way out. Everything feels hopeless like there is no light at the end of the tunnel. Amladi says this can lead to a feeling of failure and worthlessness. In more serious cases, it can lead to suicidal thoughts or actions.
• Depression also has a significant impact on sleep. This often manifests as trouble falling asleep, staying asleep, frequent nighttime awakening, or feeling tired upon waking despite getting an adequate number of hours of sleep. “This can lead to a feeling of exhaustion and low energy which can prevent people from even being able to get out of bed, or perform daily activities like showering, eating and brushing their teeth,” Amladi says. 
• Sometimes depression can be physically painful. Amladi says it is not unusual for people with depression to feel body aches, headaches, muscle tension, and even nausea.

Information presented in this article may be triggering to some people. If you are having suicidal thoughts, contact the  National Suicide Prevention Lifeline  at  988  for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911. 

For more mental health resources, see our  National Helpline Database .

How It Feels According to People With Depression

Leela R. Magavi , MD, psychiatrist, and regional medical director for Community Psychiatry , says the most common question asked in her practice is: "How does depression feel?"

“Some people ask me this question for comfort and to ensure that they are not alone with their experience, while others feel so confused by their tumultuous feelings that they struggle to clearly identify their inner experience,” she says. 

With that in mind, here are some of the responses Magavi hears in her sessions:

• "Depression feels like a weight on my chest, which brings me down everywhere I go."
• "Depression is receiving praise at work but still feeling worthless."
• "Depression is the loneliness I feel when I see other couples and families laughing and enjoying their lives."
• "Depression is feeling like I am a failure as a person, family member, and friend."
• "Depression is when I cannot take care of my children because I cannot take care of myself."
• "Depression is not brushing my hair and teeth because I simply cannot move."
• "Depression is smiling when others laugh, hiding behind the fabricated mask, and wishing I could just disappear."
• "Depression is my life and shadow, which haunts me every day."

Christian Sismone, someone who has dealt with depression and anxiety her entire life, says it’s important to provide a non-clinical perspective. She shares these examples:

• “Depression makes my mind feel like a turtle running in chunky peanut butter.” Sismone says this is most evident when she is not able to have clear thoughts. 
• “Depression feels like I'm suffocating in my emotions, and at times I feel as though I can breathe, but only through a straw.” Being someone who attempted to end their life 10 years ago, Sismone says the complicated emotion of depression can feel too great.
• “Depression can feel like an old friend that doesn't quite fit, but you know the ins and outs.” For Sismone, learning how to work with depression instead of running away from it, helped her move forward.

What Are the Different Types of Depression?

Since depression is such a complex disorder, it can be difficult to define and diagnose with just one set of generalized criteria. Because of this, other categories define different types of depression. 

According to the National Institute of Mental Health, the two most common forms of depression are major or clinical depression and persistent depressive disorder.

Major depression is the most commonly diagnosed form of depression characterized as having symptoms of depression most of the day, nearly every day for at least two weeks that interferes with your ability to work, sleep, study, eat, and enjoy life.

Persistent depressive disorder dysthymia is diagnosed after a person has symptoms of depression that last for at least two years. 

Other forms of depression include: 

• Perinatal or prepartum depression , which occurs during pregnancy.
• Postpartum depression , which after pregnancy and childbirth. 
• Seasonal affective disorder (SAD) , which features depressive episodes that come and go with the seasons.
• Psychotic depression , which co-occurs with one other form of psychosis.
• Premenstrual dysphoric disorder (PDD) , which is a severe extension of premenstrual syndrome.

Common Signs and Symptoms of Depression

Depressive symptoms can range from mild to severe and include:

• Loss of interest or pleasure in actives you used to enjoy
• Feelings of hopelessness, worthlessness, and pessimism (expecting only bad things to occur)
• Irritability
• Difficulty sleeping 
• Changes in appetite 
• Lack of energy
• Difficulty concentrating, remembering, or making decisions
• Increase in aches and pains, headaches, digestive problems
• Lack of self-care (not bathing, grooming, etc)
• Withdraw from social activities
• Thoughts of death or suicide, or suicide attempts

Tips for Friends and Family 

If you have a friend or loved one dealing with depression, you might be wondering if there are things you should look or listen for. The good news, according to Kevin Gilliland, PsyD, a licensed clinical psychologist and executive director of Innovation360, is you don’t need to have a great understanding of what depression feels like to you, just try to be curious about what depression feels like for them.

His advice? Try to understand it enough so that you stay aware of the symptoms and look for the little things that indicate your loved one is doing well or that they are struggling.

“What’s most important is that we are trying to care for them and when we are aware of their struggle, we can check on them and ask what we can do to help, ” Gilliland says. 

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A Word From Verywell

Depression is a serious mental health issue. Although symptoms can look different depending on the severity, it’s not uncommon to experience many of the feelings described above.

That said, if you’re experiencing more than a few symptoms of depression or are worried that your symptoms are worsening, it may be time to schedule an appointment with your doctor or mental health expert. 

National Institute of Mental Health. Depression Basics.

National Institute of Mental Health. Major Depression .

By Sara Lindberg, M.Ed Sara Lindberg, M.Ed., is a freelance writer focusing on mental health, fitness, nutrition, and parenting.

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How does depression affect the body?

The effects of depression may extend beyond a person’s emotions and mental health. Depression can also affect a person’s physical health.

In this article, learn about these physical effects of depression , including chronic pain, weight changes, and increased inflammation .

What is depression?

Depression is a complex mental health condition that causes a person to have low mood and may leave them feeling persistently sad or hopeless.

Depressive symptoms can be a temporary experience in response to grief or trauma. But when the symptoms last longer than 2 weeks, it can be a sign of a serious depressive disorder.

The same symptoms can also be a sign of another mental health condition, such as bipolar or post-traumatic stress disorder (PTSD).

The Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) lists the following symptoms of depression:

• depressed mood on most days, including feelings of sadness or emptiness
• loss of pleasure in previously enjoyed activities
• too little or too much sleep most days
• unintended weight loss or gain or changes in appetite
• physical agitation or feelings of sluggishness
• low energy or fatigue
• feeling worthless or guilty
• trouble concentrating or making decisions
• intrusive thoughts of death or suicide

The symptoms vary between individuals and may change over time. For a doctor to diagnose depression, a person must have five or more symptoms that must be present during the same 2-week period.

Physical symptoms of depression

Research has documented many ways that depression can affect physical health, including the following:

Weight gain or loss

People with depression may experience appetite changes, which can cause unintended weight loss or gain.

Medical experts have associated excessive weight gain with many health issues, including diabetes and heart disease . Being underweight can harm the heart, affect fertility, and cause fatigue.

Chronic pain

People with depression may experience unexplained aches or pains , including joint or muscle pain, breast tenderness, and headaches .

A person’s depression symptoms can worsen because of chronic pain.

Heart disease

Depression can reduce a person’s motivation to make positive lifestyle choices. Their risk of heart disease increases when they eat a poor diet and have a sedentary lifestyle.

Depression may also be an independent risk factor for heart health problems. According to research published in 2015 , one in five people with heart failure or coronary artery disease has depression.

Inflammation

Research indicates that chronic stress and depression are linked to inflammation and may change the immune system. Other research suggests that depression could be due to chronic inflammation.

People with depression are more likely to have inflammatory conditions or autoimmune disorders, such as irritable bowel syndrome (IBS), type 2 diabetes , and arthritis .

However, it is unclear whether depression causes inflammation or chronic inflammation makes someone more vulnerable to depression. More research is necessary to understand the link between the two.

Sexual health problems

People with depression may have a decreased libido, have trouble becoming aroused, no longer have orgasms, or have less pleasurable orgasms.

Some people also experience relationship problems due to depression, which can have an impact on sexual activity.

Worsening chronic health conditions

People who already have a chronic health condition may find their symptoms are worse if they develop depression.

Chronic illnesses may already feel isolating or stressful, and depression may exacerbate these feelings.

A person with depression may also struggle to follow the treatment plan for a chronic illness, which can allow the symptoms to get worse.

People who experience depression and who have a chronic illness should talk to a doctor about strategies for addressing both conditions. Preserving mental health may improve physical health and make a chronic condition easier to manage.

Trouble sleeping

People with depression may experience insomnia or trouble sleeping.

This condition can leave them feeling exhausted, making it difficult to manage both physical and mental health.

Doctors link sleep deprivation to a host of health problems. Similarly, research has correlated long-term sleep deprivation with high blood pressure , diabetes, weight-related issues, and some types of cancer .

Gastrointestinal problems

People with depression often report stomach or digestion problems, such as diarrhea , vomiting, nausea, or constipation . Some people with depression also have chronic conditions, including IBS.

According to research published in 2016 , this may be because depression changes the brain’s response to stress by suppressing activity in the hypothalamus, pituitary gland, and adrenal glands.

Recognizing that depression can cause physical health problems can help a person to seek treatment and make changes to help manage their symptoms.

Depression is treatable. A doctor may recommend a combined approach, using medication, therapy, and lifestyle changes. With the right support, a person can manage both physical and mental health effects of depression.

Last medically reviewed on July 9, 2018

How we reviewed this article:

• Blumenthal, J. A., Smith, P. J., & Hoffman, B. M. (2013, July 1). Is exercise a viable treatment for depression?  ACSM's Health & Fitness Journal ,  16 (4), 14–21 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674785/
• Cohen, B. E., Edmondson, D., & Kronish, I. M. (2015, April 24). State of the art review: Depression, stress, anxiety, and cardiovascular disease.  American Journal of Hypertension ,  28 (11), 1295–1302 https://academic.oup.com/ajh/article/28/11/1295/2743312
• Coryell, W. (2018, May). Depressive disorders https://www.merckmanuals.com/professional/psychiatric-disorders/mood-disorders/depressive-disorders
• Karling, P., Wikgren, M., Adolfsson, R., & Norrback, K.-F. (2016, April). Hypothalamus-pituitary-adrenal axis hypersuppression is associated with gastrointestinal symptoms in major depression.  Journal of Neurogastroenterology and Motility ,  22 (2), 292–303 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4819868/
• Leonard, B. E. (2010, December 15). The concept of depression as a dysfunction of the immune system.  Current Immunology Reviews ,  6 (3), 205–212 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002174/
• Liu, H., Waite, L., Shen, S., & Wang, D. (2016, October 6). Is sex good for your health? A national study on partnered sexuality and cardiovascular risk among older men and women.  Journal of Health and Social Behavior , 57 (3), 276–296 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5052677
• Medic, G., Wille, M., & Hemels, M. E. H. (2017, May 19). Short- and long-term health consequences of sleep disruption.  Nature and Science of Sleep ,  9 , 151–161 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5449130/
• Miller, A. H., & Raison, C. L. (2017, August 3). The role of inflammation in depression: From evolutionary imperative to modern treatment target.  Nature Reviews Immunology ,  16 (1), 22–34 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542678/
• Rantala, M. J., Luoto, S., Krams, I., & Karlsson, H. (2018, March). Depression subtyping based on evolutionary psychiatry: Proximate mechanisms and ultimate functions [Abstract].  Brain, Behavior, and Immunity ,  69 , 603–617 https://www.ncbi.nlm.nih.gov/pubmed/29051086
• Reynolds, C. R., & Kamphaus, R. W. (2013). Major depressive disorder https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_MajorDepressiveDisorder.pdf

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Science News

A chemical imbalance doesn’t explain depression. so what does, the causes of depression are much more complex than the serotonin hypothesis suggests.

Understanding depression means not only studying the brain and body, but also a host of outside factors that influence people’s health, researchers argue.

PETER STRAIN

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By Laura Sanders

February 12, 2023 at 7:00 am

You’d be forgiven for thinking that depression has a simple explanation.

The same mantra — that the mood disorder comes from a chemical imbalance in the brain — is repeated in doctors’ offices, medical textbooks and pharmaceutical advertisements. Those ads tell us that depression can be eased by tweaking the chemicals that are off-kilter in the brain. The only problem — and it’s a big one — is that this explanation isn’t true.

The phrase “chemical imbalance” is too vague to be true or false; it doesn’t mean much of anything when it comes to the brain and all its complexity. Serotonin, the chemical messenger often tied to depression, is not the one key thing that explains depression. The same goes for other brain chemicals.

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The hard truth is that despite decades of sophisticated research, we still don’t understand what depression is. There are no clear descriptions of it, and no obvious signs of it in the brain or blood.

The reasons we’re in this position are as complex as the disease itself. Commonly used measures of depression, created decades ago, neglect some important symptoms and overemphasize others, particularly among certain groups of people. Even if depression could be measured perfectly, the disorder exists amid myriad levels of complexity, from biological confluences of minuscule molecules in the brain all the way out to the influences of the world at large. Countless combinations of genetics, personality, history and life circumstances may all conspire to create the disorder in any one person. No wonder the science is stuck.

It’s easy to see why a simple “chemical imbalance” explanation holds appeal, even if it’s false, says Awais Aftab, a psychiatrist at Case Western Reserve University in Cleveland. What causes depression is nuanced, he says — “not something that can easily be captured in a slogan or buzzword.”

So here, up front, is your fair warning: There will be no satisfying wrap-up at the end of this story. You will not come away with a scientific explanation for depression, because one does not exist. But there is a way forward for depression researchers, Aftab says. It requires grappling with nuances, complexity and imperfect data.

Those hard examinations are under way. “There’s been some really interesting and exciting scientific and philosophical work,” Aftab says. That forward motion, however slow, gives him hope and may ultimately benefit the millions of people around the world weighed down by depression.

How is depression measured?

Many people who feel depressed go into a doctor’s office and get assessed with a checklist. “Yes” to trouble sleeping, “yes” to weight loss and “yes” to a depressed mood would all yield points that get tallied into a cumulative score. A high enough score may get someone a diagnosis. The process seems straightforward. But it’s not. “Even basic issues regarding measurement of depression are actually still quite open for debate,” Aftab says.

That’s why there are dozens of methods to assess depression, including the standard description set by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders , or DSM-5. This manual is meant to standardize categories of illness.

Variety in measurement is a real problem for the field and points to the lack of understanding of the disease itself, says Eiko Fried, a clinical psychologist at Leiden University in the Netherlands. Current ways of measuring depression “leave you with a really impoverished, tiny look,” Fried says.

Scales can miss important symptoms, leaving people out. “Mental pain,” for instance, was described by patients with depression and their caregivers as an important feature of the illness , researchers reported in 2020 in Lancet Psychiatry . Yet the term doesn’t show up on standard depression measurements.

One reason for the trouble is that the experience of depression is, by its nature, deeply personal, says clinical psychologist Ioana Alina Cristea of the University of Pavia in Italy. Individual patient complaints are often the best tool for diagnosing the disorder, she says. “We can never let these elements of subjectivity go.”

In the middle of the 20th century, depression was diagnosed through subjective conversation and psychoanalysis, and considered by some to be an illness of the soul. In 1960, psychiatrist Max Hamilton attempted to course-correct toward objectivity. Working at the University of Leeds in England, he published a depression scale. Today, that scale, known by its acronyms HAM-D or HRSD, is one of the most widely used depression screening tools, often used in studies measuring depression and evaluating the promise of possible treatments.

Who is depressed?

According to data from 2020, an estimated 21 million adults in the United States have had a major depressive episode in the last year, putting the overall prevalence at 8.4 percent. Rates are notably higher among females, people ages 18 to 25 and people who reported belonging to two or more races. But the widely varied scales used to diagnose depression may not accurately capture the true rates among some populations.

Portion of U.S. adults who have had a major depressive episode in the last year

“It’s a great scheme for a scale that was made in 1960,” Fried says. Since the HRSD was published, “we have put a man on the moon, invented the internet and created powerful computers small enough to fit in people’s pockets,” Fried and his colleagues wrote in April in Nature Reviews Psychology . Yet this 60-year-old tool remains a gold standard.

Hamilton developed his scale by observing patients who had already been diagnosed with depression. They exhibited symptoms such as weight loss and slowed speech. But those mixtures of symptoms don’t apply to everyone with depression, nor do they capture nuance in symptoms.

To spot these nuances, Fried looked at 52 depression symptoms across seven different scales for depression, including Hamilton’s scale. On average, each symptom appeared in three of the seven scales. A whopping 40 percent of the symptoms appeared in only one scale, Fried reported in 2017 in the Journal of Affective Disorders . The only specific symptom common to all seven scales? “Sad mood.”

In a study that examined depression symptoms reported by 3,703 people, Fried and Randolph Nesse, an evolutionary psychiatrist at the University of Michigan Medical School in Ann Arbor, found 1,030 unique symptom profiles . Roughly 14 percent of participants had combinations of symptoms that were not shared with anyone else, the researchers reported in 2015 in the Journal of Affective Disorders .

Before reliable thermometers, the concept of temperature was murky. How do you understand the science of hot and cold without the tools to measure it? “You don’t,” Fried says. “You make a terrible measurement, and you have a terrible theory of what it is.” Depression presents a similar challenge, he says. Without good measurements, how can you possibly diagnose depression, determine whether symptoms get better with treatments or even prevent it in the first place?

Depression differs by gender, race and culture

The story gets murkier when considering who these depression scales were made for. Symptoms differ among groups of people, making the diagnosis even less relevant for certain groups.

Depression symptoms measured by seven scales

Seven common rating tools for depression measure a wide variety of symptoms. When researchers reviewed the 52 symptoms measured by these scales, only one specific symptom appeared in all seven — sad mood.

Behavioral researcher Leslie Adams of Johns Hopkins Bloomberg School of Public Health studies depression in Black men. “It’s clear that [depression] is negatively impacting their work lives, social lives and relationships. But they’re not being diagnosed at the same rate” as other groups, she says. For instance, white people have a lifetime risk of major depression disorder of almost 18 percent; Black people’s lifetime risk is 10.4 percent , researchers reported in 2007 in JAMA Psychiatry . This discrepancy led Adams to ask: “Could there be a problem with diagnostic tools?”

Turns out, there is. Black men with depression have several characteristics that common scales miss , such as feelings of internal conflict, not communicating with others and feeling the burdens of societal pressure, Adams and colleagues reported in 2021 in BMC Public Health . A lot of depression measurements are based on questions that don’t capture these symptoms, Adams says. “ ‘Are you very sad?’ ‘Are you crying?’ Some people do not emote in the same way,” she says. “You may be missing things.”

American Indian women living in the Southeast United States also experience symptoms that aren’t adequately caught by the scales, Adams and her team found in a separate study. These women also reported experiences that do not necessarily signal depression for them but generally do for wider populations.

On common scales, “there are some items that really do not capture the experience of depression for these groups,” Adams says. For instance, a common question asks how well someone agrees with the sentence: “I felt everything I did was an effort.” That “can mean a lot of things, and it’s not necessarily tied to depression,” Adams says. The same goes for items such as, “People dislike me.” A person of color faced with racism and marginalization might agree with that, regardless of depression, she says.

Our ways to measure depression capture only a tiny slice of the big picture. The same can be said about our understanding of what’s happening in the brain.

The flawed serotonin hypothesis

Serotonin came into the spotlight in part because of the serendipitous discovery of drugs that affected serotonin receptors, called selective serotonin re­uptake inhibitors, or SSRIs. After getting its start in the late 1960s, the “serotonin hypothesis” flourished in the late ’90s, as advertisers ran commercials that told viewers that SSRIs fixed the serotonin deficit that can accompany depression. These messages changed the way people talked and thought about depression. Having a simple biological explanation helped some people and their doctors, in part by easing the shame some people felt for not being able to snap out of it on their own. It gave doctors ways to talk with people about the mood disorder.

But it was a simplified picture. A recent review of evidence, published in July in Molecular Psychiatry , finds no consistent data supporting the idea that low serotonin causes depression. Some headlines declared that the study was a grand takedown of the serotonin hypothesis. To depression researchers, the findings weren’t a surprise. Many had already realized this simple description wasn’t helpful.

There’s plenty of data suggesting that serotonin, and other chemical messengers such as dopamine and norepinephrine, are somehow involved in depression, including a study by neuropharmacologist Gitte Moos Knudsen of the University of Copenhagen. She and colleagues recently found that 17 people who were in the midst of a depressive episode released, on average, less serotonin in certain brain areas than 20 people who weren’t depressed. The study is small, but it’s one of the first to look at serotonin release in living human brains of people with depression.

But Knudsen cautions that those results, published in October in Biological Psychiatry , don’t mean that depression is fully caused by low serotonin levels. “It’s easy to defer to simple explanations,” she says.

SSRIs essentially form a molecular blockade, stopping serotonin from being reabsorbed into nerve cells and keeping the levels high between the cells. Those high levels are thought to influence nerve cell activity in ways that help people feel better.

Because the drugs can ease symptoms in about half of people with depression, it seemed to make sense that depression was caused by problems with serotonin. But just because a treatment works by doing something doesn’t mean the disease works in the opposite way. That’s backward logic , psychiatrist Nassir Ghaemi of Tufts University School of Medicine in Boston wrote in October in a Psychology Today essay. Aspirin can ease a headache, but a headache isn’t caused by low aspirin.

“We think we have a much more nuanced picture of what depression is today,” Knudsen says. The trouble is figuring out the many details. “We need to be honest with patients, to say that we don’t know everything about this,” she says.

The brain contains seven distinct classes of receptors that sense serotonin. That’s not even accounting for sensors for other messengers such as dopamine and norepinephrine. And these receptors sit on a wide variety of nerve cells, some that send signals when they sense serotonin, some that dampen signals. And serotonin, dopamine and norepinephrine are just a few of dozens of chemicals that carry information throughout a multitude of interconnected brain circuits. This complexity is so great that it renders the phrase “chemical imbalance” meaningless.

Overly simple claims — low serotonin causes depression, or low serotonin isn’t involved — serve only to keep us stymied, Aftab says. “[It] just keeps up that unhelpful binary.”

How treatment helps depression patients

A large study called STAR*D enrolled more than 4,000 people with depression across the United States and offered a window into how well treatment works. In the study, volunteers who didn’t respond to one treatment were switched to a second and so on. At each step, the portion of people in remission increased, though gains were smaller for later steps.

Depression remission rate with treatments

Depression research can’t ignore the world

In the 1990s, Aftab says, depression researchers got intensely focused on the brain. “They were trying to find the broken part of the brain that causes depression.” That limited view “really hurt depression research,” Aftab says. In the last 10 years or so, “there’s a general recognition that that sort of mind-set is not going to give us the answers.”

Reducing depression to specific problems of biology in the brain didn’t work, Cristea says. “If you were a doctor 10 years ago, the dream was that the neuroscience would give us the markers. We would look at the markers and say, ‘OK. You [get] this drug. You, this kind of therapy.’ But it hasn’t happened.” Part of that, she says, is because depression is an “existentially complicated disorder” that’s tough to simplify, quantify and study in a lab.

Our friendships, our loves, our setbacks and our stress can all influence our health. Take a recent study of first-year doctors in the United States. The more these doctors worked, the higher the rate of depression , scientists reported in October in the New England Journal of Medicine . Similar trends exist for caregivers of people with dementia and health care workers who kept emergency departments open during the COVID-19 pandemic. Their high-stress experiences may have prompted depression in some way.

“Depression is linked to the state of the world — and there is no denying it,” Aftab says.

What depression scales don’t ask

In a concept mapping study, descriptions of depression symptoms provided by Black men and key individuals supporting Black men’s health, including Black women and doctors, were clustered into six categories: physical states, emotional states, diminished drive, communication with others, internal conflict and social pressures. Communication with others and internal conflict were each asked about in only one of three commonly used depression assessments studied. Social pressures weren’t reflected in any of the three assessments.

Reflected in three assessments

Physical states: Descriptions in this category included high blood pressure, self-harm or suicidal behavior, binge eating, insomnia, heart palpitations and weight loss and/or gain.

Emotional states: Descriptions in this category included not being able to “get up and go,” a lack of motivation, anger, fatigue, hopelessness, frustration, worry, bursts of crying, low self-esteem, feeling stuck and feeling out of control.

Diminished drive: This category included descriptions of an untidy appearance, the inability to complete tasks and life goals, not being able to provide for family and excessive substance use, such as marijuana, cigarettes and alcohol.

Reflected in one assessment

Communication with others: Descriptions in this category included not being able to communicate properly, including ignoring emails and phone calls, isolation from others, withdrawal from everyday activities, volatile behavior toward others, blunted emotional expression and difficulty maintaining romantic relationships.

Internal conflict: This category included having a pessimistic outlook, feeling guilty, feeling unqualified, feeling attacked or defensive, feeling helpless in the face of aging, and a heightened sense of fear or dread.

Not reflected in the assessments

Social pressures: Descriptions in this category included not being able to keep up appearances, fear of unknown consequences of today’s political environment, adherence to cultural norms of success and power, a lack of work/life balance, seeking happiness through accumulated materials and increased attendance at religious institutions.

Today’s research on depression ought to be more pluralistic, Adams says. “There are so many factors at play that we can’t just rest on one solution,” she says. Research from neuroscience and genetics has helped identify brain circuits, chemical messengers, cell types, molecules and genes that all may be involved in the disorder. But researchers aren’t satisfied with that. “There is other evidence that remains unexplored,” Adams says. “With our neuro­science advances, there should be similar advances in public health and psychiatric work.”

That’s happening. For her part, Adams and colleagues have just begun a study looking at moment-to-moment stressors in the lives of Black adolescents, ages 12 to 18, as measured by cell phone questionnaires. Responses, she hopes, will yield clues about depression and risk of suicide.

Other researchers are trying to fit together all of these different ways of seeing the problem. Fried, for example, is developing new concepts of depression that acknowledge the interacting systems. You tug on one aspect of it — using an antidepressant for instance, or changing sleep patterns — and see how the rest of the system reacts.

Approaches like these recognize the complexity of the problem and aim to figure out ways to handle it. We will never have a simple explanation for depression; we are now learning that one cannot possibly exist. That may sound like cold comfort to people in depression’s grip. But seeing the challenge with clear eyes may be the thing that moves us forward.

What you think you know about depression is probably wrong

We’ve all heard that depression is caused by a chemical imbalance in the brain, but science shows that the truth is much more complex.

What is the serotonin hypothesis of depression?

The serotonin hypothesis says that depression is caused by not enough of a chemical messenger called serotonin in the brain. A related idea is that brain chemicals are out of balance.

Why did it become popular?

Drugs called SSRIs were advertised as ways to treat depression by fixing the serotonin deficit. These drugs ease symptoms for roughly half of people with depression.

Why is the serotonin hypothesis of depression wrong?

It is too simple a picture. There are no clear descriptions of depression, and no obvious signs of it in the brain or blood. All sorts of factors influence depression, ranging from a myriad of minuscule molecules in the brain to events in a person’s life.

What factors need to be considered when studying depression?

Symptoms of depression vary widely from person to person, and common depression scales can miss important symptoms. Signs of depression also vary among different groups of people, and can be influenced by race, gender and culture. What’s more, our friendships, our loves, our setbacks and our stress can all influence our mental health.

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• Diseases & Conditions
• Teen depression

Teen depression is a serious mental health problem that causes a persistent feeling of sadness and loss of interest in activities. It affects how your teenager thinks, feels and behaves, and it can cause emotional, functional and physical problems. Although depression can occur at any time in life, symptoms may be different between teens and adults.

Issues such as peer pressure, academic expectations and changing bodies can bring a lot of ups and downs for teens. But for some teens, the lows are more than just temporary feelings — they're a symptom of depression.

Teen depression isn't a weakness or something that can be overcome with willpower — it can have serious consequences and requires long-term treatment. For most teens, depression symptoms ease with treatment such as medication and psychological counseling.

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Teen depression signs and symptoms include a change from the teenager's previous attitude and behavior that can cause significant distress and problems at school or home, in social activities, or in other areas of life.

Depression symptoms can vary in severity, but changes in your teen's emotions and behavior may include the examples below.

Emotional changes

Be alert for emotional changes, such as:

• Feelings of sadness, which can include crying spells for no apparent reason
• Frustration or feelings of anger, even over small matters
• Feeling hopeless or empty
• Irritable or annoyed mood
• Loss of interest or pleasure in usual activities
• Loss of interest in, or conflict with, family and friends
• Low self-esteem
• Feelings of worthlessness or guilt
• Fixation on past failures or exaggerated self-blame or self-criticism
• Extreme sensitivity to rejection or failure, and the need for excessive reassurance
• Trouble thinking, concentrating, making decisions and remembering things
• Ongoing sense that life and the future are grim and bleak
• Frequent thoughts of death, dying or suicide

Behavioral changes

Watch for changes in behavior, such as:

• Tiredness and loss of energy
• Insomnia or sleeping too much
• Changes in appetite — decreased appetite and weight loss, or increased cravings for food and weight gain
• Use of alcohol or drugs
• Agitation or restlessness — for example, pacing, hand-wringing or an inability to sit still
• Slowed thinking, speaking or body movements
• Frequent complaints of unexplained body aches and headaches, which may include frequent visits to the school nurse
• Social isolation
• Poor school performance or frequent absences from school
• Less attention to personal hygiene or appearance
• Angry outbursts, disruptive or risky behavior, or other acting-out behaviors
• Self-harm — for example, cutting or burning
• Making a suicide plan or a suicide attempt

What's normal and what's not

It can be difficult to tell the difference between ups and downs that are just part of being a teenager and teen depression. Talk with your teen. Try to determine whether he or she seems capable of managing challenging feelings, or if life seems overwhelming.

When to see a doctor

If depression signs and symptoms continue, begin to interfere in your teen's life, or cause you to have concerns about suicide or your teen's safety, talk to a doctor or a mental health professional trained to work with adolescents. Your teen's family doctor or pediatrician is a good place to start. Or your teen's school may recommend someone.

Depression symptoms likely won't get better on their own — and they may get worse or lead to other problems if untreated. Depressed teenagers may be at risk of suicide, even if signs and symptoms don't appear to be severe.

If you're a teen and you think you may be depressed — or you have a friend who may be depressed — don't wait to get help. Talk to a health care provider such as your doctor or school nurse. Share your concerns with a parent, a close friend, a spiritual leader, a teacher or someone else you trust.

Suicide is often associated with depression. If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

Also consider these options if you're having suicidal thoughts:

• Call your mental health professional.
• In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . The Spanish language phone line is 1-888-628-9454 (toll-free). Services are free and confidential.
• Or contact a crisis service for teenagers in the U.S. called TXT 4 HELP : Text the word "safe" and your current location to 4HELP (44357) for immediate help, with the option for interactive texting.
• Seek help from your primary care doctor or other health care provider.
• Reach out to a close friend or loved one.
• Contact a minister, spiritual leader or someone else in your faith community.

If a loved one or friend is in danger of attempting suicide or has made an attempt:

• Make sure someone stays with that person.
• Call 911 or your local emergency number immediately.
• Or, if you can do so safely, take the person to the nearest hospital emergency room.

Never ignore comments or concerns about suicide. Always take action to get help.

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It's not known exactly what causes depression, but a variety of issues may be involved. These include:

• Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that carry signals to other parts of your brain and body. When these chemicals are abnormal or impaired, the function of nerve receptors and nerve systems changes, leading to depression.
• Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression.
• Inherited traits. Depression is more common in people whose blood relatives — such as a parent or grandparent — also have the condition.
• Early childhood trauma. Traumatic events during childhood, such as physical or emotional abuse, or loss of a parent, may cause changes in the brain that increase the risk of depression.
• Learned patterns of negative thinking. Teen depression may be linked to learning to feel helpless — rather than learning to feel capable of finding solutions for life's challenges.

Risk factors

Many factors increase the risk of developing or triggering teen depression, including:

• Having issues that negatively impact self-esteem, such as obesity, peer problems, long-term bullying or academic problems
• Having been the victim or witness of violence, such as physical or sexual abuse
• Having other mental health conditions, such as bipolar disorder, an anxiety disorder, a personality disorder, anorexia or bulimia
• Having a learning disability or attention-deficit/hyperactivity disorder (ADHD)
• Having ongoing pain or a chronic physical illness such as cancer, diabetes or asthma
• Having certain personality traits, such as low self-esteem or being overly dependent, self-critical or pessimistic
• Abusing alcohol, nicotine or other drugs
• Being gay, lesbian, bisexual or transgender in an unsupportive environment

Family history and issues with family or others may also increase your teenager's risk of depression, such as:

• Having a parent, grandparent or other blood relative with depression, bipolar disorder or alcohol use problems
• Having a family member who died by suicide
• Having a family with major communication and relationship problems
• Having experienced recent stressful life events, such as parental divorce, parental military service or the death of a loved one

Complications

Untreated depression can result in emotional, behavioral and health problems that affect every area of your teenager's life. Complications related to teen depression may include, for example:

• Alcohol and drug misuse
• Academic problems
• Family conflicts and relationship difficulties
• Suicide attempts or suicide

There's no sure way to prevent depression. However, these strategies may help. Encourage your teenager to:

• Take steps to control stress, increase resilience and boost self-esteem to help handle issues when they arise
• Practice self-care, for example by creating a healthy sleep routine and using electronics responsibly and in moderation
• Reach out for friendship and social support, especially in times of crisis
• Get treatment at the earliest sign of a problem to help prevent depression from worsening
• Maintain ongoing treatment, if recommended, even after symptoms let up, to help prevent a relapse of depression symptoms

Teen depression care at Mayo Clinic

• Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed May 4, 2021.
• Bipolar and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed May 4, 2021.
• Brown AY. Allscripts EPSi. Mayo Clinic. April 9, 2021.
• Teen depression. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/teen-depression/. Accessed March 30, 2022.
• Depression in children and teens. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/The-Depressed-Child-004.aspx. Accessed May 4, 2021.
• Psychotherapy for children and adolescents: Different types. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychotherapies-For-Children-And-Adolescents-086.aspx. Accessed May 4, 2021.
• Suicidality in children and adolescents being treated with antidepressant medications. U.S. Food and Drug Administration. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications. Accessed May 4, 2021.
• Depression medicines. U.S. Food and Drug Administration. https://www.fda.gov/consumers/free-publications-women/depression-medicines. Accessed May 4, 2021.
• Building your resilience. American Psychological Association. https://www.apa.org/topics/resilience. Accessed May 4, 2021.
• Psychiatric medications for children and adolescents: Part I ― How medications are used. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-I-How-Medications-Are-Used-021.aspx. Accessed May 4, 2021.
• Psychiatric medications for children and adolescents: Part II ― Types of medications. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Psychiatric-Medication-For-Children-And-Adolescents-Part-II-Types-Of-Medications-029.aspx. Accessed May 5, 2021.
• Weersing VR, et al. Evidence-base update of psychosocial treatments for child and adolescent depression. Journal of Clinical Child and Adolescent Psychology. 2017; doi:10.1080/15374416.2016.1220310.
• Zuckerbrot RA, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018; doi:10.1542/peds.2017-4081.
• Cheung AH, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018; doi:10.1542/peds.2017-4082.
• Resilience guide for parents and teachers. American Psychological Association. https://www.apa.org/topics/resilience/guide-parents-teachers. Accessed May 4, 2021.
• Rice F, et al. Adolescent and adult differences in major depression symptoms profiles. Journal of Affective Disorders. 2019; doi:10.1016/j.jad.2018.09.015.
• Haller H, et al. Complementary therapies for clinical depression: An overview of systemic reviews. BMJ Open. 2019; doi:10.1136/bmjopen-2018-028527.
• Ng JY, et al. Complementary and alternative medicine recommendations for depression: A systematic review and assessment of clinical practice guidelines. BMC Complementary Medicine and Therapeutics. 2020; doi:10.1186/s12906-020-03085-1.
• American College of Obstetricians and Gynecologists. Practice Bulletin No. 92: Use of psychiatric medications during pregnancy and lactation. Obstetrics & Gynecology. 2008; doi:10.1097/AOG.0b013e31816fd910. Reaffirmed 2019.
• Neavin DR, et al. Treatment of major depressive disorder in pediatric populations. Diseases. 2018; doi:10.3390/diseases6020048.
• Vande Voort JL (expert opinion). Mayo Clinic. June 29, 2021.
• Safe Place: TXT 4 HELP. https://www.nationalsafeplace.org/ txt-4-help. Accessed March 30, 2022.
• Antidepressants for children and teens

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Exercise can help prevent and treat mental health problems, and taking it outside adds another boost to those benefits

Professor of Health Sciences, Simon Fraser University

Disclosure statement

Scott Lear receives funding from the Canadian Institutes of Health Research and Hamilton Health Sciences, and has received funding from the Heart and Stroke Foundation, Novo Nordisk, and the Robert Wood Johnson Foundation.

Simon Fraser University provides funding as a member of The Conversation CA.

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Mental health problems affect one in five people every year . The Canadian Mental Health Association estimates that by the age of 40, about half of people will either have had a mental illness or will currently be dealing with one.

Behavioural therapy and medications are common first options for treatment. However, research has shown the importance of exercise in not only preventing mental illness, but also treating it. And when exercise is taken outdoors, the benefits can be even greater.

Mental illnesses include depression, addictions and anxiety, as well as personality disorders. Of these, anxiety and depression are the most common, with depression being the leading cause of disability worldwide . Left untreated, these diseases can result in physical illness and premature death.

My research focuses on the benefits of physical activity to prevent and manage disease, and ways to make it easier for people to be active. In December 2021, I was diagnosed with major depressive disorder, and exercise and spending time in nature were vital to my recovery.

Exercise can make you happy

Exercise and activity have long been known to improve mood. A study of more than 1.2 million adults in the United States reported those who exercised had 1.5 fewer days in the past month of poor mental health . And the greatest benefits occurred in those people who exercised 45 minutes or more for three or more days per week.

But even shorter sessions can make a difference. As little as ten minutes of activity was enough to improve happiness . Over time, regular exercise can result in less likelihood for getting depression and anxiety . It also doesn’t matter what type of activity you do. Whether it’s team sports, cycling, walking, running or aerobics, all provide benefits. Even active household chores can reduce the chances for depression .

Exercise as treatment for mental illness

Numerous studies indicate exercise as an effective treatment for people with existing depression and other mental illnesses. A meta-analysis revealed as little as four weeks of exercise reduced symptoms of depression in people with major depressive disorder. This is less time than it takes for most antidepressant medications to work.

While exercise is beneficial at all intensity levels, it appears higher intensity exercise may be more effective than low intensity . Strength training can also reduce symptoms in people with depression. And a recent review of studies totalling 128,119 participants reported exercise is as effective as antidepressants for treating non-severe depression. Exercise has also been found to reduce symptoms in people with clinical anxiety and schizophrenia .

How exercise works to improve mental well-being

Exercise may improve mental well-being due to the release of hormones and brain function. Exercise results in the release of endorphins and endocannabinoids . Endorphins are the feel-good hormones that reduce pain or discomfort associated with activity. Endocannabinoids work on the same system affected by marijuana, reducing pain and improving mood.

In the brain, low levels of brain-derived neurotrophic factor (BDNF) and a smaller hippocampus have been associated with a number of mental illnesses. BDNF is important for the growth of nerves in the brain and development of new neural connections, while the hippocampus is associated with learning, memory and mood. Exercise can increase BDNF levels in people with depression , as well as increase hippocampus volume .

Take it outside

Exercising in nature can further improve mental well-being. Rumination is a negative pattern of repetitive thinking and dwelling on things. It is associated with greater chances for mental illness, but can be reduced with a walk through a natural environment . And people who spent at least two hours in nature over the course of a week reported higher well-being compared to those who had no contact with nature.

There are a number of reasons why nature is good for us. Trees are known to give off compounds called phytoncides, which have been associated with multiple health benefits . In addition, levels of cortisol (the stress hormone) are reduced with as little as 20 minutes spent in a park.

The value of being outdoors to physical and mental health was recognized by Parks Canada in January 2022, when they partnered with PaRx , an organization led by health professionals who prescribe time in nature to their patients, to allow doctors to prescribe Adult Parks Canada Discovery Passes .

With these passes, patients can access Canada’s national parks, national historic sites and national marine conservation areas. This follows similar programs in many other countries such as New Zealand, Japan, the United States and the United Kingdom.

With all the benefits of exercise and nature on mental health, it’s important to recognize some people with a mental illness can find simple daily tasks challenging. For these people taking an antidepressant and behavioural therapy may be more suitable. But for others, exercising in nature is a simple and cost-saving activity to maintain your mental health and treat mental illnesses.

Scott Lear writes a biweekly blog Become Your Healthiest You and co-hosts a monthly podcast How to Health .

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What is depression, recognize signs of low mood and depression in children and learn ways to help them feel better..

All children feel low or down at times, it’s a natural part of growing up. But these emotions can be worrisome when felt intensely over long periods of time, particularly if they affect your child’s social, family and school life.

Although it's hard for anyone to feel optimistic when they're depressed, depression can be treated and there are things you can do to help your child feel better.

What is depression?  What causes depression? Depression in children and adolescents Signs and symptoms of depression in kids Ways to help your child cope When to seek professional help

Depression is one of the most common types of mental health conditions and often develops alongside anxiety .

Depression can be mild and short-lived or severe and long-lasting. Some people are affected by depression only once, while others may experience it multiple times.

Depression can lead to suicide, but this is preventable when appropriate support is provided. It’s important to know that much can be done to help young people who are thinking about suicide.

What causes depression?

Depression can happen as a reaction to something like abuse, violence in school, the death of someone close or family problems like domestic violence or family breakdown. Someone might get depressed after being stressed for a long time. It can also run in the family. Sometimes we may not know why it happens.

>> Learn more about stress and effective ways to deal with it

Depression in children and adolescents

Depression can show up in children and adolescents as prolonged periods of unhappiness or irritability. It is quite common among older children and teenagers, but often goes unrecognized.

Some children might say they feel “unhappy” or “sad”. Others might say they want to hurt or even kill themselves. Children and adolescents who experience depression are at greater risk of self-harm, so such responses should always be taken seriously.

Just because a child seems sad, it doesn't necessarily mean they have depression. But if the sadness becomes persistent or interferes with normal social activities, interests, schoolwork or family life, it may mean they need support from a mental health professional.

Remember, only a doctor or a mental health professional can diagnose depression, so don’t hesitate to ask your health-care provider for advice if you are worried about your child.

> Discover: Tips and resources to support your family's mental health

Signs and symptoms of depression in kids

Depression can feel different for different children. Here are some of the common signs and symptoms of depression:

• Tiredness or low energy, even when rested
• Restlessness or difficulty concentrating
• Difficulty in carrying out daily activities
• Changes in appetite or sleep patterns
• Aches or pains that have no obvious cause

Emotional and mental:

• Persistent sadness, anxiousness or irritability
• Loss of interest in friends and activities that they normally enjoy
• Withdrawal from others and loneliness
• Feelings of worthlessness, hopelessness or guilt
• Taking risks they wouldn’t normally take  
• Self-harming or suicidal thoughts

Experiencing one or more of these symptoms doesn’t mean a child is affected by depression, but there are a number of ways you can help your child cope. If you are worried about your child, do not hesitate to ask your health-care provider for advice.

Ways to help your child cope

Here are some things you can do to support your child if you think they may be depressed:

• Find out what’s happening: Ask them how they’re feeling and listen openly without judgment or advice. Ask people you trust who know your child, like a favourite teacher or close friend, to find out if they’ve noticed anything that might be worrying them or changes in their reactions to things. Pay particular attention to their well-being during important life changes like starting a new school or puberty.
• Spend time with them: Try to build an environment of warmth, reassurance and support by talking or doing age-appropriate activities together that they will enjoy. Take an interest in their life, like how their day was at school or what they love most about their friends.
• Encourage positive habits: Encourage your child to do the things they usually enjoy, stick to regular eating and sleeping habits and stay active. Physical activity is an important way to boost their mood. Music can have a strong influence on our moods, so try listening to songs together that make them feel positive about life.
• Let them express themselves: Let them talk to you. Listen carefully to what they say about how they feel. Never press your child to share, instead you can encourage other forms of creative expression like painting, crafts or journaling their thoughts and experiences. Mood-journaling can help some children let their feelings out by observing the things that make them upset or low. They can also be a great reminder of the positive aspects of their life and the things they are proud of.
• Protect them from stressful surroundings: Try to keep your child away from situations where they may experience excessive stress, maltreatment or violence. And remember to model healthy behaviour and reactions to the stresses in your own life, including setting boundaries and maintaining positive self-care habits.

When to seek professional help

As depression can only be diagnosed by a qualified expert, it's important to seek help from your health care provider who may refer your child to a mental health expert or psychiatrist. If the mental health expert thinks your child would benefit from treatment, the options might include some form of talk therapy – where they learn how to manage their thoughts and feelings, or a combination of therapy and medication.

If your child has thoughts of self-harm, or has already self-harmed, seek help from emergency services or a health-care professional. Don’t delay getting in touch if you’re worried.

Depression can be treated and the sooner you speak to an expert, the sooner your child can feel better.

Mental health and well-being

Tips and resources to help you support your child and yourself

What is anxiety?

Feelings of anxiety among children are preventable and treatable

What are panic attacks?

Understanding the triggers is the first step to helping your child overcome the condition

What is stress?

A common feeling that affects children as much as adults, just differently

Exploring the relationship between welfare participation in childhood and depression in adulthood in the United States

Downloadable content.

• Other Affiliation: Arizona State University
• Affiliation: University of North Carolina at Chapel Hill
• Other Affiliation: Columbia University
• Other Affiliation: Saint Louis University
• OBJECTIVE: Depression is a serious mental health disorder, and untangling its causal agents is a major public health priority in the United States. This study examines the relationship between participating in welfare programs during childhood and experiencing depression during young adulthood. METHOD: This study used wave I and IV data from the Add Health (N = 15,701). Multiple imputation is used to deal with missing data. Propensity score matching is used to reduce the selection bias, and then multiple regressions were used to examine the welfare participation and depression relationships. RESULTS: Overall, young adults from welfare-recipient families reported significantly higher depression scores, rather than the clinical diagnosis of depression. Subgroup analyses showed only the poor group had significantly higher depression scores, whereas only the near-poor group had a significantly diagnosed depression outcome. Additionally, significantly higher depression scores were found for female youth from welfare-recipient families. However, no significant differences were found between the gender groups regarding diagnosed depression. DISCUSSION: Using welfare participation as an economic marker, the subgroup analyses help to identify target populations for future intervention. Implications of this study will be of interest to policy makers and have value for informing policy decisions.
• Child poverty
• Welfare participation
• Social determinate of health
• https://doi.org/10.17615/hzgm-at11
• https://dx.doi.org/10.1016/j.ssresearch.2018.08.009
• Social Science Research

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Digital cognitive behavioral therapy for insomnia on depression and anxiety: a systematic review and meta-analysis

• Suonaa Lee   ORCID: orcid.org/0000-0003-1801-3267 1   na1 ,
• Jae Won Oh   ORCID: orcid.org/0000-0002-5379-9907 2   na1 ,
• Kyung Mee Park   ORCID: orcid.org/0000-0002-2416-2683 1 , 2 ,
• San Lee   ORCID: orcid.org/0000-0003-4834-8463 1 , 2 &
• Eun Lee   ORCID: orcid.org/0000-0002-7462-0144 1 , 3  

npj Digital Medicine volume  6 , Article number:  52 ( 2023 ) Cite this article

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Despite research into the development of digital cognitive behavioral therapy for insomnia (dCBT-I), research into the outcomes of dCBT-I on insomnia and the associated clinical conditions of depression and anxiety have been limited. The PubMed, PsycINFO (Ovid), Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) on adult patients with insomnia also having reported measures of depressive or anxiety symptoms. In total, 2504 articles were identified after duplicate removal, and 22 RCTs were included in the final meta-analysis. At the post-treatment assessment, the dCBT-I group had a small to moderate effect in alleviating depressive (standardized mean difference (SMD) = −0.42; 95% CI: −0.56, −0.28; p  < 0.001; k  = 21) and anxiety symptoms (SMD = −0.29; 95% CI: −0.40, −0.19; p  < 0.001; k  = 18), but had a large effect on sleep outcome measures (SMD = −0.76; 95% CI: −0.95, −0.57; p  < 0.001; k  = 22). When considering treatment adherence, the treatment effects of those in the high adherent groups identified a more robust outcome, showing greater effect sizes than those in the low adherent groups for depression, anxiety, and sleep outcomes. Furthermore, additional subgroup analysis on studies that have used the fully automated dCBT-I treatment without the support of human therapists reported significant treatment effects for depression, anxiety, and sleep outcomes. The results demonstrated that digital intervention for insomnia yielded significant effects on alleviating depressive and anxiety symptoms as well as insomnia symptoms. Specifically, the study demonstrated significant effects on the above symptoms when considering treatment adherence and implementing fully automated dCBT-I.

Introduction

Insomnia is one of the most common sleep disorders, posing a significant public health concern, with an estimated prevalence of 10–30% among adults in the general population 1 , 2 . These numbers are greater among patients, with reports estimating 69% prevalence among primary care patients 3 . Insomnia disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders – IV (DSM-IV) as the complaint for difficulty in initiating or maintaining sleep, or restorative sleep for at least 1 month 4 . Such sleep disturbances may cause clinically significant distress or impairment in social, occupational, or other areas of functioning. Apart from fatigue, insomnia has also been associated mental disorders, low work productivity, and cognitive impairment. Despite its high prevalence and potentially severe consequences, only a limited number of people seek treatment for insomnia 5 .

Depression and anxiety are the most common comorbid mental disorders associated with insomnia which can also exacerbate the sleep disorder 6 , 7 . Recently, epidemiologic studies have reported that insomnia predicts the development of major depression, anxiety, and suicide. Various cross-sectional and longitudinal research have presented insomnia to be associated with an increased risk of mood and anxiety disorders as well as suicide. Those with insomnia reported increased odds of depression and anxiety as compared to those without 8 . Sleep disturbances are detected among 90% of patients with clinical depression 9 , and those with insomnia are ten times more likely to experience clinical depression 10 . As a result, insomnia can be considered a subsequent risk factor for depression due to its bidirectional relationship with depression. Likewise, insomnia is also the most prevalent sleep disturbance associated with anxiety disorders as poor sleep quality has been found among adults with anxiety disorders. In the Diagnostic and Statistical Manual for Mental disorders, fifth edition (DSM-5), sleep disturbances are one of the diagnostic criteria for generalized anxiety disorder, which is characterized by excessive anxiety and worry about certain events or activities. Moreover, studies have found generalized anxiety disorder to be the most prevalent psychiatric diagnosis among patients with insomnia, thus presenting as a significant comorbid disorder 11 .

Cognitive behavioral therapy for insomnia (CBT-I) has been an effective non-pharmacological treatment for insomnia. It is a multi-component, evidence-based treatment and is considered the first-line approach including cognitive restructuring, sleep restriction, stimulus control, sleep hygiene education, and relaxation 12 , 13 . Due to the association between insomnia and depression, CBT-I has been viewed an effective approach for managing depression 14 . A systematic review of CBT-I to treat depression revealed CBT-I as a promising treatment for depression comorbid with insomnia, with in-person CBT-I delivery having the most supporting evidence in its efficacy among 18 studies that included CBT-I, prescription medication or sleep hygiene as its treatment methods 14 . In addition, study findings suggest that insomnia improvement from CBT-I may also mediate the reduction in depressive symptoms. Likewise, in addition to depression, CBT-I demonstrated moderate to large effect sizes for generalized anxiety disorder symptoms 15 . These findings indicate that CBT-I is not only effective for treating insomnia and sleep-related disorders but also for treating comorbid mental disorders including depression and anxiety.

Whilst such a traditional approach of CBT-I has been proven effective, there are certain limitations of this therapeutic method including the lack of therapists, time and geographical limitations, and high costs. With the advent of technology, digital CBT-I (dCBT-I), which is the implementation of technology in computers, the internet, smartphone applications, and other devices in healthcare service have been developed and researched over the last decade 13 , 16 . dCBT-I programs are not only structured with the main key components of CBT-I but also provide additional levels of personalized support to enhance user engagement, including the use of email reminders, alerts, etc. Furthermore, dCBT-I users can evaluate their sleep status through online sleep diaries, questionnaires, or syncing with other devices such as wrist-worn actigraphs, to track certain sleep patterns and collect the ecological momentary assessment. A meta-analysis found that internet-based CBT-I had significantly improved insomnia severity and sleep parameters in addition to comorbid factors of depression and anxiety, maintaining such improvements at a 6-month follow-up. According to these results, dCBT-I is an effective treatment alternative for insomnia, both in terms of clinical effectiveness and positive user satisfaction whilst also demonstrating that the treatment was effective in improving comorbid anxiety and depression with a mild strength 12 .

However, despite the research on the effects of dCBT-I, further investigations are needed to evaluate the outcomes of dCBT-I on insomnia and the comorbid factors depression and anxiety, as only a small handful of studies were included in the previous meta-analysis 17 . Furthermore, the implications of the treatment adherence and the effects of therapist’s involvement when using such treatment methods has received relatively little attention 18 . Thus, the current meta-analysis aimed to assess the effects of dCBT-I on depression and anxiety symptoms as well as insomnia and other sleep parameters, including total sleep time (TST), sleep efficiency (SE), sleep onset latency (SOL), and wake after sleep onset (WASO) by pooling published randomized control trials (RCTs). This would assist in determining the efficacy of dCBT-I on insomnia as well as the most typical comorbid factors, depression and anxiety, with in consideration of adherence rates and in-person involvement of the therapists. Furthermore, adherence rates must be taken into account to establish whether an outcome is related to a certain treatment 19 . Whilst there are various studies that investigate mobile health (mHealth) devices supporting patients and healthcare systems for medication adherence 20 , 21 , a robust definition of adherence rate in actual treatment methods delivered using mHealth technology is currently absent. A review of mHealth technology identified adherence can be measured in various methods such as the number of logins, completed modules, pages viewed and completed self-reported measures 22 . Others also suggested the usage time of these devices 23 . Following these prior studies and their definitions of mHealth technology adherence, we have defined adherence based on the percentage of participants who had fully completed the provided dCBT-I sessions.

The flow of study selection is presented in the PRISMA flow diagram (Fig. 1 ). A total of 2504 articles were identified after duplicate removal, of which, 73 articles were assessed for full-text review. A final sample of 22 RCTs was included in the meta-analysis.

Search and study selection process.

Study characteristics

The characteristics of the 22 studies included in the meta-analysis are described in Table 1 . The meta-analysis included a total of 10,486 participants, of whom 5494 were randomized to the dCBT-I group, with a median study size of 111 participants (range 21–3755 participants). The overall mean age of dCBT-I and control groups was 43.8 ± 8.7 years and 43.6 ± 8.3 years, respectively. Participants in control conditions received active interventions including sleep education or general health education (not specifically targeting sleep), or passive controls including treatment as usual and wait-lists. All studies used a parallel design, with 20 studies using two-arm trials and two studies using three-arm trials. For treatment groups, the dCBT-I therapy sessions ranged between 5 and 8 sessions with an average of 6.18 sessions across the included studies. The studies were mostly conducted in Europe ( n  = 13) and the United States ( n  = 5). Baseline mean depression scores from measurements indicated 11 studies included participants with subthreshold symptoms of depression, 1 study included participants with clinically significant depression symptoms, and 9 studies with participants having no depression symptoms. Baseline mean anxiety scores from measurements indicated 9 studies included participants with subthreshold symptoms of anxiety and 7 studies with no anxiety symptoms. One study used anxiety measurement that did not provide a cut-off score for interpretation 24 . By providing only mean difference in anxiety, it was difficult to obtain baseline mean anxiety scores in the study conducted by Glozier et al 25 . Furthermore, among the 22 studies included, 12 reported completion rates for dCBT-I sessions, with the average completion rate of 59.73%.

Risk of bias

The risks of bias for the included studies were assessed using the Cochrane Risk of Bias tool – version 2 26 and the results are presented in Supplementary Fig. 1 . The overall risk of bias was low for 8 studies, moderate for 10, and high for the remaining 4 studies across five domains. A significant risk of bias was detected from the measurement of the outcome domain, predominantly due to studies utilizing self-rating questionnaires as their primary outcomes. Furthermore, blinding of participants and research personnel may have also contributed to deviations from the intended intervention.

Treatment effects

Depression measures.

Twenty-one out of 22 studies reported the severity of depressive symptoms. The outcome measures of depressive symptoms varied across studies including Center for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire-9 (PHQ-9), Patient Health Questionnaire-2 (PHQ-2), Edinburgh Postnatal Depression Scale (EPDS), Allgemeiner Depressions-Skala (ADS-K), Montgomery–Åsberg Depression Rating Scale (MADRS), Hospital Anxiety and Depression Scale-Depression (HADS-D), Beck Depression Inventory (BDI-II), and Quick Inventory of Depressive Symptomatology (QIDS). At the post-treatment assessment, we found a small to moderate effect favoring dCBT-I (Fig. 2 ; Standardized Mean differences (SMD) = −0.42; 95% confidence interval (CI): −0.56, −0.28; p  < 0.001; k  = 21). The statistical heterogeneity in effect sizes among studies was high ( I 2  = 81.79; Q  = 109.85; df = 20; p  < 0.001).

Forest plot of studies reporting the effect of dCBT-I on depression.

Anxiety measures

Eighteen out of 22 studies reported the severity of anxiety symptoms. The outcome measures of anxiety symptoms varied across studies including General Anxiety Disorder-7 (GAD-7), General Anxiety Disorder-2 (GAD-2), Hospital Anxiety and Depression Scale-Anxiety (HADS-A), Brief Symptom Inventory-Anxiety (BSI-Anxiety), and Beck Anxiety Inventory (BAI). For anxiety symptoms at the post-treatment assessment, we found a small to moderate effect favoring dCBT-I (Fig. 3 ; SMD = −0.29; 95% CI: −0.40, −0.19; p  < 0.001; k  = 18). The statistical heterogeneity in effect sizes among studies was high ( I 2  = 57.75; Q  = 40.24; df = 17; p  < 0.001).

Forest plot of studies reporting the effect of dCBT-I on anxiety.

Sleep measures

The sleep outcome measures varied across studies and included Insomnia Severity Index (ISI), Sleep Condition Indicator (SCI), and Pittsburgh Sleep Quality Index (PSQI). Where available, ISI was chosen for the main sleep outcome measurement. All but three studies used ISI as an outcome for insomnia severity. These studies were Bostock et al. (2016), Espie et al. (2019) and van Straten et al. (2014). Among the three remaining studies, two studies used the SCI, while one study used the PSQI measure. For the severity of insomnia post-treatment, we found a large effect favoring dCBT-I (Fig. 4 ; SMD = −0.76; 95% CI: −0.95, −0.57; p  < 0.001; k  = 22). The statistical heterogeneity in effect sizes among studies was high ( I 2  = 90.59; Q  = 223.04; df = 21; p  < 0.001). In studies including only ISI, we found a large effect favoring dCBT-I (Supplementary Fig. 3 ; SMD = −0.81; 95% CI: −0.97, −0.65; p  < 0.001; I 2  = 79.51; k  = 19).

Forest plot of studies reporting the effect of dCBT-I on sleep outcome and sleep efficiency.

For sleep diary outcomes, the effect was significant with a moderate to large effect size for SE (Fig. 4 ; SMD = 0.53; 95% CI: 0.28, 0.78; p  < 0.001; I 2  = 68.91; k  = 9), SOL (Supplementary Fig. 2 ; SMD = −0.65; 95% CI: −1.14, −0.15; p  = 0.01; I 2  = 89.00; k  = 8) and WASO (Supplementary Fig. 2 ; SMD = −1.48; 95% CI: −2.76, −0.20; p  = 0.03; I 2  = 97.17; k  = 5), while the effect was significant with a small effect size for TST (Supplementary Fig. 2 ; SMD = 0.26; 95% CI: 0.04, 0.50; p  = 0.02; I 2  = 53.03; k  = 9).

Sensitivity analysis

Sensitivity analysis was conducted by removing two studies including participants with medical comorbidities (cancer and epilepsy) and one study with major depressive disorder. After excluding the studies, robust treatment effects of dCBT-I were demonstrated for depression (Supplementary Fig. 4 ; SMD = −0.41; 95% CI: −0.56, −0.25; p  < 0.001; I 2  = 83.36; k  = 18), anxiety (Supplementary Fig. 5 ; SMD = −0.30; 95% CI: −0.40, −0.19; p  < 0.001; I 2  = 58.17; k  = 15) and sleep (Supplementary Fig. 6 ; SMD = −0.74; 95% CI: −0.95, −0.53; p  < 0.001; I 2  = 91.40; k  = 19) outcomes. When sensitivity analysis was performed after excluding 4 studies with high risk of bias, the treatment effects were robust for depression (SMD = −0.40; 95% CI: −0.55, −0.25; p  < 0.001; I 2  = 83.84; k  = 18), anxiety (SMD = −0.29; 95% CI: −0.41, −0.18; p  = 0.001; I 2  = 65.13; k  = 14), and sleep outcomes (SMD = −0.74; 95% CI: −0.95, −0.53; p  < 0.001; I 2  = 91.86; k  = 18).

Subgroup analysis

Treatment adherence.

Additional subgroup analysis was performed on 12 studies that reported the number of participants who completed the dCBT-I sessions. To compare the effect of treatment adherence, we divided 12 studies into two groups: (1) high adherent group with >65% of dCBT-I completers; (2) low adherent group with <65% of dCBT-I completers. The treatment effects of the high adherent group were significant for depression (SMD = −0.60; 95% CI: −0.72, −0.47; p  < 0.001; I 2  = 0.00; k  = 5), anxiety (SMD = −0.32; 95% CI: −0.61, −0.02; p  = 0.03; I 2  = 38.58; k  = 4) and sleep outcomes (SMD = −1.12; 95% CI: −1.30, −0.95; p  < 0.001; I 2  = 15.17; k  = 5). See Fig. 5 for the detailed results of this analysis. For the low adherent group, the treatment effects were also significant but effect sizes were smaller than those in adherent groups for depression (SMD = −0.35; 95% CI: −0.57, −0.14; p  = 0.001; I 2  = 88.71; k  = 7), anxiety (SMD = −0.28; 95% CI: −0.45, −0.11; p  = 0.001; I 2  = 82.34; k  = 6), and sleep outcomes (SMD = −0.69; 95% CI: −1.05, −0.34; p  < 0.001; I 2  = 95.82; k  = 7).

Forest plot of studies reporting the effect of dCBT-I among dCBT-I completers with more than 65% of completion rate.

Effects of fully automated dCBT-I

The additional subgroup analysis was performed on 14 studies using fully automated dCBT-I without support of human therapists. The treatment effects of the fully automated dCBT-I were significant for depression (SMD = −0.43; 95% CI: −0.61, −0.26; p  < 0.001; I 2  = 88.14; k  = 13), anxiety (SMD = −0.29; 95% CI: −0.41, −0.17; p  = 0.001; I 2  = 68.46; k  = 12), and sleep outcomes (SMD = −0.81; 95% CI: −1.04, −0.59; p  < 0.001; I 2  = 92.69; k  = 14). The detailed results of this analysis are presented in Supplementary Fig. 7 .

Publication bias

Visual inspection of funnel plots, (Supplementary Fig. 8 for sleep outcome, Supplementary Fig. 9 for depression, and Supplementary Fig. 10 for anxiety) and Egger’s tests for asymmetry in funnel plots were used to estimate publication bias. The Egger’s tests were not significant for depression ( t  = 0.03, df = 19, p  = 0.98), anxiety ( t  = 0.02, df = 16, p  = 0.98), and insomnia ( t  = 0.63, df = 20, p  = 0.54), indicating no significant publication bias.

The current meta-analysis aimed to assess the efficacy of dCBT-I and examine the impact of adherence to dCBT-I on treatment outcomes of depressive and anxiety symptoms, and sleep disorders. By pooling the data obtained from eligible RCTs, our results demonstrated that digital intervention for insomnia yielded significant effects at post-treatment as compared to control conditions on alleviating depressive and anxiety symptoms as well as insomnia symptoms, SE, TST, SOL, and WASO.

The results were comparable to the findings reported in the previous meta-analysis examining the effects of dCBT-I on depression and anxiety, which showed small to moderate effects on depression and anxiety 27 . However, the previous study was limited by the relatively small number of available studies (10 RCTs). With a substantially larger sample size of 22 RCTs, this updated meta-analysis further supported the efficacy of dCBT-I. Furthermore, we extended the findings of the meta-analysis conducted by Ye et al., by demonstrating that fully automated dCBT-I interventions without the support of human therapists, are also effective for improving conditions of depression and anxiety 12 . One previous study demonstrated a fully automated dCBT-I integrated into an existing UK-based clinical service, demonstrating its effectiveness in alleviating depression, anxiety, and insomnia 28 . Given that published trials on the automated dCBT-I implementations in real-world environments are scarce, the potential effects of a fully automated version of dCBT-I for people with depression or anxiety warrant further evaluation.

Although the pooled effect of dCBT-I on depressive and anxiety symptoms is small to moderate, there was considerable heterogeneity in the magnitude of the effects observed. This heterogeneity is comparable to previous research 29 and expected given the diversity of participants recruited, outcome measures, the delivery format of CBT-I, and baseline severity levels of depression and anxiety in the included studies. The effects of dCBT-I interventions on depression and anxiety symptoms were relatively robust after removing the three studies that included participants with mental or medical comorbidities. Considering that the majority of the studies included in this meta-analysis had subclinical depression and anxiety samples, this suggests that dCBT-I interventions are beneficial in reducing subclinical depression and anxiety symptoms. Whilst dCBT-I is developed for insomnia treatment, current findings suggest that dCBT-I has the capability for an effective supplementary therapy beyond its current potential.

Apart from the mitigation of depression and anxiety symptoms, the improvement in insomnia severity in this study is generally well in line with those reported in a previous meta-analytic review of dCBT-I for insomnia severity, SE, TST, SOL, and WASO 13 . Nonetheless, a direct comparison with the meta-analysis conducted by Soh et al. is difficult as they calculated the effect size as mean differences 13 . This shows dCBT-I as an effective treatment method, not just as an adjunct to pharmacological or psychotherapeutic treatment for depression and anxiety.

Prior research has reported treatment adherence to be positively associated with treatment effectiveness of technology-mediated treatments 30 . As an extension of this, our study investigated the effects of dCBT-I adherence on depression, anxiety, and insomnia outcomes by considering the proportion of the participants who completed all dCBT-I sessions. The effect sizes for depression, anxiety, and insomnia severity were comparatively greater in high adherent group although the treatment effects were significant in low adherent groups as well. This presents the adherence moderates the effect of the dCBT-I intervention.

Nonetheless, previous research has identified that even the most effective apps have minimal effect if these lack user engagement, resulting in a high attrition rate 31 . The attrition-efficacy gap needs to be settled especially for those requiring sustained mental health treatment 32 . The problem of high dropout rates is especially true for fully automated dCBT-I intervention without any support of human therapists 32 , 33 . Therefore, adherence-promoting features such as ease of use, rewards, ability to personalize app, tailored interventions, social or peer support in app, personalized feedback, and integration with clinical services should be considered 34 . Although there’s lacking evidence in research comparing the differences between automated support and with or without human support, automated reminders have increased enhanced adherence to treatment 35 . The fears around security and privacy inherent to digital interventions might be an additional factor in adherence and attrition for some participants, therefore user safety should be considered upfront 32 . Furthermore, most studies showed various methods to assess adherence, which make it difficult to compare outcomes meaningfully, though adherence was most often assessed by the degree of program completion 36 . Therefore, a standardized method for assessing adherence is required to reliably predict the impacts of adherence on treatment outcomes.

Given that few of the studies included in the current review involve participants with clinically significant level of depression and anxiety symptoms, our result of significant effects favoring dCBT-I could be seen as pertaining to patients with subthreshold level of depression and anxiety symptoms. In a previous study of internet-delivered CBT-I, when comparing the differences between severe and low to mildly depressed patients, those with severe symptoms more likely to benefit from human support of reminding and encouraging patients by e-mail, while those with low level of depressive symptoms were demonstrated to benefit adequately regardless of the support 37 . This indicates that the addition of some guidance could be preferred depending on the baseline severity of depression although fully automated intervention increases scalability. Thus, further research is needed to determine the role of symptom severity of depression and anxiety for the effect of digital intervention.

This meta-analysis supports the efficacy of dCBT-I on insomnia and subclinical symptoms of depression and anxiety symptoms. The current study demonstrated small-to-moderate effect sizes, which was consistent with prior meta-analyses conducted to evaluate the effectiveness of cognitive behavior therapies for depression, anxiety, and sleep disorders 38 . Studies have identified mostly small to moderate effect when having treatment as usual or pill placebo as the control condition 39 . Henceforth, based on these results the small-to-moderate effects of dCBT-I treatment can be considered as a clinically meaningful outcome. This study also demonstrated that fully automated dCBT-I interventions were able to alleviate comorbid depression and anxiety symptoms with insomnia. To the best of our knowledge, there haven’t been earlier studies conducting meta-analysis to investigate the treatment effect of fully automated dCBT-I. Overall, the results demonstrate greater effect sizes for patients utilizing fully automated dCBT-I, in addition to the significant effects of treatment adherence.

This meta-analysis had some limitations. First, 12 out of 22 studies had a small sample size of <50 which could lead to an overestimation of effect sizes. Second, due to the heterogeneity in the details reported, long-term outcomes were difficult to evaluate between studies. Also, details regarding the baseline severity of depression and anxiety of the participants were also not clearly presented; therefore, it was difficult to identify differences between the studies included. Further studies especially inclusive of individuals with clinical depression or anxiety should be explored. Finally, the control groups were not consistent among the included studies comparing the dCBT-I group intervention with the waitlist, treatment as usual, and psychoeducation, implicating the heterogeneity of the analyses. To explore and determine the effectiveness of dCBT-I, future research should first consider having a consistent control group in addition to potentially comparing the dCBT-I with individual face-to-face CBT-I interventions. Furthermore, whilst the current study did not investigate the interaction effects between adherence levels with the type of dCBT-I delivery, whether or not the treatment delivery was fully automated, future studies may consider this interaction effect in their research. The outcomes may show a clinically meaningful interpretation regarding adherence levels and the different types of dCBT-I treatment delivery.

The results of our meta-analysis emphasize the need for CBT-I by digital means in patients with depression and anxiety symptoms. Since dCBT-I can be implemented globally, further research is needed to provide sufficient clinical evidence of its effectiveness, especially in the fully automated version in comparison to the traditional methods of face-to-face CBT-I.

Data sources and searches

This study was conducted in reference to the Cochrane Handbook for Systematic Reviews of Interventions 40 and reported according to the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 41 . The review protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO), registration number: CRD42022315203. There was no prior published protocol for the current study. Furthermore, PubMed, Embase, PsycINFO, and Cochrane databases were accessed to search for studies published from inception to January 15th, 2022. Full search strategies are attached in Supplementary Table 1 .

Study selection

The following inclusion criteria were established for study selection: (1) comprised adult patients aged ≥18 years; (2) have been formally diagnosed or had self-reported symptoms of insomnia defined by any edition of the DSM 42 , International Classification of Sleep Disorders 43 , or International Classification of Diseases; 44 (3) with reported measures of depressive or anxiety symptoms; (4) involving a dCBT-I intervention delivered by digital technology including computer, Internet and smartphone applications, alongside a control group with other interventions for managing insomnia, active controls, waitlist, or participants who underwent usual care; (5) adopted an RCT design. In the current study, dCBT-I consisted of multimodal components with at least one key cognitive strategy (cognitive restructuring) and one key behavioral strategy (stimulus control or sleep restriction). Henceforth, only CBT-I methods were considered as treatment methods for this study. Furthermore, as long as the main CBT-I treatment methods were delivered via a digital device listed above, studies with additional feedback interactions via online guidance, emails and text messages were also considered to meet the selection criteria. The two researchers (SAL, JWO) independently extracted and reviewed the studies to consider their inclusion based on the eligibility criteria. Duplicate articles were removed; titles and abstracts were screened for study inclusion. Full texts of the remaining studies were further reviewed. The two reviewers (SAL, JWO) assessed inter-rater reliability using Cohen’s Kappa value, keeping the researchers blinded to each other’s decisions throughout the review process. All authors discussed any disagreement between studies and reached a consensus. The inter-rater reliability of study selection was considered strong (Kappa = 0.82).

Data extraction and risk of bias assessment

Two authors (SAL, JWO) each extracted data from the included studies. Details including title, authors, year of publication, study design, number of dCBT-I sessions, and treatment duration were extracted in addition to sample size, mean age of each intervention, and control groups. Moreover, assessment tools were used to evaluate the relevant study variables, and pre and post-scores of both intervention and control groups were extracted. Any discrepancies were resolved through discussion among all authors.

The revised Cochrane risk of bias tool for randomized trials was used by the two researchers, independently assessing the risk of bias of each included study. Five different domains were assessed: (1) randomization process; (2) deviations from intended interventions; (3) missing outcome data; (4) measurement of the outcome; and (5) selection of the reported result. The risk of bias was assessed and reported as “low risk,” “some concerns,” or “high risk of bias.” Again, any discrepancies in the results were discussed to reach a consensus.

Treatment outcomes

Self-reported insomnia-related measures including ISI, SCI, and PSQI were evaluated in addition to various sleep diary outcomes such as TST, SE, SOL, and WASO. Symptoms of depression were measured using the CES-D, PHQ-9, PHQ-2, EPDS, ADS-K, MADRS, HADS-D, and BDI-II. Whereas, GAD-7, GAD-2, HADS-A, BSI-Anxiety, and BAI were used to assess anxiety. These outcome measures were used to determine the efficacy of dCBT-I delivery approaches. Any missing information from the included studies was obtained by contacting the original study authors via email.

Data synthesis and analysis

Statistical analyses were performed using Comprehensive Meta-Analysis software (version 3; Biostat Inc., Englewood, New Jersey, USA). SMDs with 95% CIs were reported for sleep diary measures, insomnia, depression, and anxiety symptoms. The overall between-group SMDs were calculated based on the differences in the post-intervention outcome measures between the dCBT-I intervention and control groups. Changes between baseline and post-intervention were not evaluated. This is in accordance with previous studies which have conducted analysis on between-group comparison of post treatment values 29 . Studies have demonstrated analyzing SMDs of post scores only is less prone to bias in comparison to utilizing the change value between baseline and post means, hence advising to avoid pre-post effect sizes in meta-analyses 45 , 46 . A pairwise meta-analysis was performed using the Der-Simonian and Laird random-effects model to compare the treatment effect differences. Heterogeneity was assessed using the Cochrane Q test with a statistical significance of P  < 0.05 and I 2 statistics. Egger’s test was also used to assess the potential publication bias.

Furthermore, subgroup analysis for the adherence of participants was performed. As per the aim of the study, adherence in this analysis was defined as the percentage of dCBT-I treatment module completers in each study included. Studies were divided into those with high adherence in comparison to those with low. Considering the variation of the participants’ treatment completion between the studies, a threshold value was determined based on prior research into adherence to insomnia treatment. A meta-analysis on the technology-mediated insomnia treatments found user adherence reported in various forms, including self-report measures and treatment program completion based on user login frequency recordings 30 . Approximately 41% of the participants met the adherence criteria based on the submitted response of self-report assessments, whilst user logs found 64% of participants completed the required sessions. From the two measures, an average of 52% of insomnia patients had completed their treatments and relevant self-report assessments. Another systematic review into the adherence of cognitive behavioral therapy for insomnia reported a mean adherence rate of 65.5% 47 . Thus, in line with these studies, the threshold value for the current meta-analysis was set at 65%, whereby studies with more than 65% participant who have completed the provided dCBT-I programs were determined as high treatment adherent studies.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

Data collected and used in this meta-analysis can be requested from the corresponding author.

Code availability

No custom code or mathematical algorithms were used this study.

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Acknowledgements

The National Research Foundation of Korea funded by the Ministry of Science, ICT & Future Planning, Republic of Korea, supported the present study (Grant number: 2022R1A2B5B03002611).

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These authors contributed equally: Suonaa Lee, Jae Won Oh.

Authors and Affiliations

Department of Psychiatry and the Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea

Suonaa Lee, Kyung Mee Park, San Lee & Eun Lee

Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea

Jae Won Oh, Kyung Mee Park & San Lee

Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Republic of Korea

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S.A.L. and J.W.O. are contributed equally as first authors of this paper, conducted the searches, screened the search records and full-text papers against the eligibility criteria and extracted the study characteristics and effect size data. Data analysis and preliminary paper was also drafted by S.A.L and J.W.O., and S.L. advised on the data-extraction and analysis as well as providing overall feedback on the paper. E.L and K.M.P also provided guidance and feedback to the paper in preparation for the final paper development. S.L and E.L provided shared supervision of the overall project and are co-corresponding authors.

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Lee, S., Oh, J.W., Park, K.M. et al. Digital cognitive behavioral therapy for insomnia on depression and anxiety: a systematic review and meta-analysis. npj Digit. Med. 6 , 52 (2023). https://doi.org/10.1038/s41746-023-00800-3

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DOI : https://doi.org/10.1038/s41746-023-00800-3

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