Depression (DSM-5): symptoms, causes and treatment

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What are the depression symptoms and characteristics in men and women according to DMS-5, what causes depression and what can you do about it? Depression occurs when someone is unusually sad for more than two weeks and/or no longer enjoys anything. This is accompanied by a number of other complaints, such as sleep disorders, reduced appetite, little energy, fatigue, concentration problems, indecisiveness, sluggishness, physical restlessness, feelings of guilt, excessive thoughts about death or suicide. The complaints disrupt daily functioning and there is psychological suffering. Depression is treated by a combination of talking (therapy) and pills (antidepressants). In 2023, there are increasing indications that nutrition can also play an important role in combating depression.

  • Depression symptoms and characteristics DSM-5
  • Course and duration of depression
  • Duration
  • Variable and erratic course
  • Disabling disorder
  • Manifestations of depression
  • Physical and other complaints
  • Culture
  • Older age
  • Younger children
  • Prevent
  • Causes and risk factors of depression
  • Vulnerability-stress model
  • Gender and age
  • Individual vulnerability
  • Social environmental factors
  • Life events
  • Organic factors
  • Biogenetic factors
  • Biochemical factors
  • Brain activity of people with depression
  • Comorbidity
  • Mental disorders or complaints
  • Anxiety disorders
  • Herbal medicine
  • Saffron
  • John’s wort
  • Rhodiola rosea (rose root)
  • Depression treatment
  • First-step interventions
  • Psychotherapy and medicine
  • Clinical treatment or day treatment
  • Ketamine treatment
  • Electroconvulsive therapy (ECT)
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
  • Deep Brain Stimulation (DBS)
  • Prognosis
  • Full recovery is an exception
  • Recurrence or chronic depression
  • Suicide in treatment-resistant depression
  • Prevention
  • Precautionary actions
  • Preventing depression from coming back
  • Depression and nutrition
  • Adapted Mediterranean diet
  • Probiotics

 

Depression / Source: Johan Larson/Shutterstock.com

Depression symptoms and characteristics DSM-5

A sad, depressed mood in response to disappointment or loss is a normal condition. Such a mood drop or grief reaction is transient and does not require targeted intervention. Colloquially, the term ‘depressed’ is often used when someone is in a slump or is somewhat depressed. However, one speaks of a depressive disorder when there is a persistent depressive mood, which is present almost daily and for most of the day, or when there is a persistent lack of zest for life, which is reflected in a decrease in interest and pleasure.

DSM-5 Not every depressive, gloomy or sad mood is a depression. Depression is a mood disorder. Below are the classification criteria according to DSM-5.

A. According to the widely used psychiatric classification system DSM-5, depression occurs when at least five of the following symptoms are present within the same two-week period and indicate a change from the person’s previous functioning. At least one of the symptoms is:

  • a gloomy mood; either
  • loss of interest and pleasure.

These are the two core symptoms or characteristics of a depressive disorder. (NB: This should not include symptoms that can clearly be attributed to a general medical condition.)

The nine symptoms of a depressive disorder according to the DSM-5 are:

  1. Depressed mood almost all day, almost every day. This can be determined by the person himself or by others. Children and adolescents may experience irritable mood.
  2. Marked loss of interest or pleasure in all, or almost all, activities for most of the day, almost every day. This can be determined by the person himself or by others.
  3. Unintentional, marked weight loss or unintentional weight gain, or a decrease or increase in appetite respectively. In children, the expected weight gain may not occur.

Fatigue and feeling of exhaustion due to depression / Source: Istock.com/BartekSzewczyk

  1. Sleep complaints: insomnia, i.e. not being able to sleep (enough), or hypersomnia, i.e. having to sleep too much, almost every day.
  2. Psychomotor agitation or inhibition almost every day.
  3. Fatigue or loss of energy almost every day.
  4. Feelings of worthlessness, or excessive or inadequate (unjustified) feelings of guilt.
  5. Reduction in the ability to think, concentrate, or indecisiveness.
  6. Feelings of despair, recurring thoughts of suicide, fantasies about suicide without specific plans, a suicide attempt or a specific plan to commit suicide. Not just the fear of dying.
  1. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Manual for the Classification of Mental Disorders (DSM-5) / Source: DSM-5

  1. The episode cannot be attributed to the physiological effects of a substance or to a general medical condition. The symptoms could not be better attributed to a mood disorder due to a general medical condition (e.g. hypothyroidism, which is an underactive thyroid gland), mood disorder due to a grief reaction (a normal reaction to the death of a loved one, the loss of work, etc.) . The symptoms are not due to the direct physiological effects of a substance (for example, a drug of abuse or a drug).

    ยป Criteria AC together indicate a depressive episode .

    D. The occurrence of the depressive episode cannot be explained by a schizoaffective disorder, schizophrenia, a schizophreniform disorder, a delusional disorder, or by any other specified or unspecified schizophrenia spectrum or other psychotic disorder.

    E. A manic or hypomanic episode has never occurred. This exclusion does not apply if the maniform or hypomaniform episodes are caused by a substance or medication or are attributable to the physiological effects of a general medical condition.

    A distinction is made between a single or a recurrent episode, as well as the severity, the presence of psychotic features and the degree of remission. When specifying the current severity, a distinction is made between mild, moderate and severe (based on the number of criterion symptoms, the severity of those symptoms and the degree of impairment in functioning):

  • Mild Not or hardly more symptoms than are required to assign the classification are present; the intensity of the symptoms causes some distress but is manageable and the symptoms lead to a slight deterioration in social, academic or occupational functioning.
  • Moderate The number of symptoms, the intensity of the symptoms and/or the limitation in functioning are between the description of ‘mild’ and ‘severe’.
  • Severe The number of symptoms is significantly greater than necessary for the classification; the intensity of the symptoms causes severe distress, and the symptoms are uncontrollable and hinder social, academic or occupational functioning.

Menstruation Many women experiencing a depressive episode report that symptoms worsen a few days before the onset of menstruation.

Course and duration of depression

Duration

There is therefore a fairly high threshold that must be met before one can speak of a depressive episode. At least five symptoms must be present at the same time, almost every day for at least two weeks. Symptoms normally develop over days or weeks. Before a full-blown depressive episode, the person may experience anxiety or mild depression. The duration of depression varies, but an untreated episode normally lasts six months or more.

Variable and erratic course

Depression has a variable and erratic course. It turns out that half of depressive episodes last less than three months, while twenty percent last longer than two years. This is also called chronic depression. A large proportion of patients experience complete remission of symptoms and return to their previous level of functioning. In 20 to 30 percent of patients, some of the complaints may remain present for months or even years (partially in remission). Many patients have recurrent episodes. It appears that in 40% of people with depression the disorder returns within two years.

Disabling disorder

Depression is a disabling mental disorder. Depression can result in reduced social, emotional and physical functioning and an increase in absenteeism due to illness. It is emotionally difficult and stressful for the patient’s environment (partner, children).

Manifestations of depression

Physical and other complaints

Depression can be overlooked because many patients with a depressive disorder present with a range of physical complaints and leave their psychological complaints unmentioned. The picture can also be complicated because depressed patients often have all kinds of (phobic) anxiety symptoms. Many patients also report to their GP with sleep complaints. Depression often starts with sleep disturbances, but also with emotional flatness, loss of interest and pleasure, fatigue, changed dietary habits and reduced sex drive.

Culture

Furthermore, a person’s culture can significantly influence the experience and expression of depressive complaints. In some cultures, complaints of sadness and guilt will be expressed in a somatic way.

Older age

With depression in old age, the negative symptoms of depression are often in the foreground and not the pronounced sadness with feelings of guilt and insufficiency.[1] What is then noticeable is the loss of interests and pleasure, lethargy and sluggishness, and anxiety complaints. Somatic and cognitive symptoms may also be presented, such as fatigue, insomnia, weight loss due to lack of appetite, fatigue and concentration and memory disorders.

Younger children

Younger children can also suffer from depression. Children with depression are mainly irritable and busy instead of gloomy and lethargic. This often makes recognizing depression in children difficult. The child often feels worthless and unloved and is excessively preoccupied with death. It often has a pessimistic and negative view of its own life. A depressed child also experiences problems with friendships, because he withdraws from social interactions or shows aggressive behavior. Girls often withdraw and boys are more likely to exhibit unruly behavior. Loss of appetite and unexplained physical pain are also common. Sleep problems, nightmares, fatigue, reduced concentration and poorer school performance are other common symptoms.

Prevent

18.7% of the Dutch population under the age of 65 has suffered from depression at some point in their lives. Depression is almost twice as common in women as in men. Nearly 25% of women have suffered from depression at some point in their lives. In men, this percentage is just over 13% (Nemesis-2, de Graaf et al., 2010).

Causes and risk factors of depression

Vulnerability-stress model

The cause or reason for depression is often not clear. In any case, there is no single cause for depression. Depression is multifactorial. The vulnerability-stress mode, also known as the stress-vulnerability model, can be helpful as an explanation for the development of depressive episodes. The model indicates which factors play a role in the outbreak of depression. The model assumes that on the one hand the individual carries a certain vulnerability (vulnerability – or the predisposition for the disorder) and that on the other hand environmental factors (stress sources) play a role in its development. These factors are therefore not separate from each other, but interact with each other.

What are the factors that contribute to the development of depression? There is no single cause for depression . The development of depression involves a combination of the following factors [2/3].

Gender and age

Women are almost twice as likely to be affected by depression than men, especially between the ages of 18 and 24.[4]

Individual vulnerability

  • Hereditary burden (decreases with increasing age);
  • Having previously experienced depression;
  • Neurotic personality;
  • Internalizing coping style in the face of setbacks, frustration and criticism (exaggeration, avoidance, self-blame and feelings of guilt);
  • Chronic physical illness or other mental disorders;
  • Homosexuality in adult men and women.

 

For example, hearing loss is related to the development of depressive symptoms in subsequent years. This applies not only to severe to profound hearing loss, but new research shows that mild and moderate hearing loss also pose a risk.[5]

 

Social environmental factors

  • Low educated;
  • The lack of a paid job;
  • Lack of or lack of social support or intimate contacts (single and divorced people are more vulnerable, but also consider living in a neighborhood with limited social cohesion)[6];
  • Perceived ethnic discrimination (experiencing unequal treatment in daily life based on origin)[7];
  • Detention;
  • Caring for a partner with dementia or Parkinson’s.

 

Life events

  • Traumatic childhood experiences, including sexual abuse, maltreatment and emotional neglect;
  • Experiencing traumatic events (such as with refugees);
  • Other stressful life events on an interpersonal level (especially women) or health-related events, such as decline in physical health (especially older people).

 

Excessive alcohol consumption can trigger depression / Source: Istock.com/Csaba Deli

Organic factors

  • Certain medications and different types of drugs (some high blood pressure medications, sleep aids, alcohol, amphetamines and cocaine) are known to potentially cause depression.*
  • Vitamin deficiencies: Research shows that low vitamin D levels predispose to depression.[8/9] A vitamin B-12 deficiency (and a deficiency of other B-vitamins such as vitamin B-6) is also associated with depression.[ 10]
  • Mineral deficiency: a magnesium deficiency can lead to depression.[11] Selenium deficiency as well as selenium excess have also been linked to depression in young adults.[12]

There are also a number of physical conditions that increase the risk of depression, such as cerebral hemorrhage and Parkinson’s disease . Research shows that patients with diabetes mellitus have a higher risk of developing depression, even before the diagnosis of ‘diabetes mellitus’ has been made (prediabetes). Physiological mechanisms may underlie this association.[13] Furthermore, certain depression can be directly traced to an overactive immune system. People with an autoimmune disease such as rheumatism, multiple sclerosis or Crohn’s disease have a higher risk of depression (see below).

(*) If there is use or abuse of a drug, stimulant or other substance and the depression arose during recent use or the recent cessation or reduction of use of the substance in question, the diagnosis is ‘substance-induced mood disorder’. ‘ stated.

Depression due to overactive immune system possible.
PhD candidate Floor van Heesch from Utrecht University discovered that certain depression can be directly traced to an overactive immune system. People with an autoimmune disease such as rheumatism, multiple sclerosis or Crohn’s disease have a higher risk of depression. Research shows that depression in these patients does not have to have a psychological cause but can be directly linked to the overactive immune system. Utrecht University reports this.

The immune system protects the body against viruses and bacteria that enter the body. The immune system then produces certain substances, cytokines, that activate the immune system. These cytokines also reach the brain via the blood. There they enhance the discharge (reuptake) of so-called messenger substances such as dopamine and serotonin that are necessary to experience a feeling of pleasure and satisfaction. Cytokines have an inhibitory effect on the reward system in the brain. This is evident from research in the brains of rats. The suppressive effect of immune activation on the reward system is so strong that it is worthwhile to also investigate it in humans, says Van Heesch. It may help explain why people with an overactive immune system due to an autoimmune disease have an increased risk of depression.

Blood collection / Source: Istock.com/anna1311

People with an autoimmune disease have an overactive immune system that attacks their own body. Patients therefore have many cytokines in the blood, which increases the risk of depression. According to Van Heesch, it is wise to always investigate whether patients with an autoimmune disease have depressive complaints. Blood tests can show whether the amount of cytokines in the blood is increased in depressed patients. Treatment with a combination of antidepressants may then be more helpful than psychotherapy. (Source: Utrecht University, 15-01-2014)

 

Biogenetic factors

There is a hereditary component that plays a role in the development of depression. Children of parents with depression are three times more likely to become depressed themselves than children of parents who are not depressed.

Pituitary gland / Source: Tefi/Shutterstock.com

Biochemical factors

It is believed that a disruption of the natural balance of certain neurotransmitters can cause depressive symptoms. Important neurotransmitters in the brain are serotonin, norepinephrine and dopamine. In addition, the substance brain-derived neurotrophic factor, abbreviated BDNF, also plays an important role. BDNF is one of the most important neurotrophic substances involved in brain diseases in general and depression in particular. Biochemical factors do not exist in isolation. Overactivity of the stress axis (the stress response or stress reaction ‘fight or flight’ is coordinated by the hypothalamus, pituitary gland and adrenal gland) appears to be an important link in the process of endocrine derailment. With a slight stimulation, a slight tension, the stress system goes into overdrive. Prolonged exposure to stress in childhood leads to dysregulation of the serotonin system and the stress axis. Overactivity of the stress axis is considered an important mechanism behind the development of depression.[14]

Brain activity of people with depression

Functional MRI (fMRI) and PET studies show that people with depression have altered brain activity: a number of brain areas appear to be more active than in non-depressed people, while other areas are more inactive. At the same time, an abnormal pattern of brain activity has been demonstrated at rest and when performing tasks. For example, at rest in the depressed patient there is less activity in, among other things, the dorsolateral prefrontal cortex (DLPFC) or cortex praefrontalis dorsolateralis, which forms the upper and outer part of the prefrontal cortex and is involved in, among other things, (working) memory, and in the subgenual cortex, that part of the hippocampus involved in the learning process. On the other hand, there is more activity in the amygdala, that part of the limbic system that is involved in emotions. The amygdala makes connections between information from different senses and links them to emotions. Research shows that after treatment with SSRIs (serotonin reuptake inhibitors), the abnormal increased activity in the amygdala normalizes. Furthermore, research shows that the reduced activity in the dorsolateral prefrontal cortex is corrected after treatment with SSRIs.[15]

 

Comorbidity

Mental disorders or complaints

Depression is often accompanied by other conditions, psychological disorders or complaints:

  • Anxiety disorders. Many people with depression suffer from anxiety, which can manifest as panic (or panic disorder), general anxiety or social phobia;
  • Anorexia nervosa;
  • Bulimia nervosa;
  • Obsessive-compulsive disorder; and
  • Borderline personality disorder .

 

Anxiety disorders

Comorbidity of anxiety disorders is common in adults with a depressive disorder. The presence of anxiety disorders is a possible predictor of the severity and course of the depressive disorder. In a study initiated by the World Health Organization (WHO), 74,045 patients from 24 countries were interviewed with a standardized psychiatric interview.[16] One-third to one-half of respondents who had ever been diagnosed with a depressive disorder reported anxiety disorders during their lifetime. In two-thirds of the patients, the anxiety disorder preceded the depressive disorder. Suicidality and role limitations were reported more often with comorbid anxiety and depression than with depressive disorder alone. In short, comorbid anxiety is not only an indicator of the severity of the depression (suicidality and loss of role), but also predicts a more persistent course with indications of reduced effectiveness of the treatment.[17]

Herbal medicine

There are some herbs that scientific research has shown can help with mild to moderate depression.

Saffron / Source: Rainer Zenz, Wikimedia Commons (Public domain)

Saffron

Saffron is a spice that is extracted from the saffron crocus, a root vegetable from the irises family. In 2023, there is no doubt that research points to the effectiveness of saffron in treating adults with mild to moderate depression and perhaps other forms of depression, such as postpartum depression (commonly called postpartum depression).[18]

St. John’s wort

St. John’s wort (Hypericum perforatum) has been proven effective in the treatment of mild to moderate depression. It is not suitable for the treatment of more severe depression, which is characterized by an inability to carry out daily activities and recurring thoughts of death or suicide. St. John’s wort is available as a herbal antidepressant.

Rhodiola rosea (rose root)

A study shows that the standardized Rhodiola rosea extract SHR-5 exhibits antidepressant activity in patients with mild to moderate depression when administered in doses of 340 or 680 mg per day for a period of 6 weeks.[19]

Depression treatment

First-step interventions

So-called ‘first-step interventions’ are offered to patients with a first mild depression. Roughly five different first-step interventions are distinguished:

  • Bibliotherapy: the use of selected reading material as a therapeutic tool;
  • Self-help or self-management (possibly including e-health, internet therapy or self-help courses against depression);
  • Activating guidance;

Psychotherapy for depression / Source: Wavebreakmedia/Shutterstock.com

  • Physical exertion/physical activity or running therapy (running therapy is the therapeutic use of ‘easy endurance running’);
  • Counseling (a little known form of guidance in the Netherlands).

 

Psychotherapy and medicine

Early intervention can prevent mild depression from developing into a disorder that is difficult to treat. However, if the above-mentioned interventions do not provide sufficient relief or if there is moderate to severe depression, psychological interventions and psychotherapy are offered in combination with drug treatment. Cognitive behavioral therapy is the most widely used and proven psychotherapeutic treatment method. A group treatment offering with mindfulness-based cognitive therapy has been developed for people with recurrent depression.

Psychotherapy for depression with a session frequency of twice a week leads to faster and better treatment outcomes and fewer dropouts than weekly sessions, according to Dutch research .[20]

Clinical treatment or day treatment

Day treatment programs exist for patients with chronic and/or recurrent depression. If the clinical picture is unclear or complex, it may be necessary to admit a patient to a special depression department.

Ketamine treatment

Ketamine is a medication used for pain or as an anesthetic. Research has shown that ketamine
can also provide a rapid and strong improvement in mood in some patients. However, as of 2023, ketamine is not registered for the treatment of depression. The Psychiatry department of the LUMC offers patients with a depressive disorder that has not responded to all usual treatments the option of so-called off-label treatment with ketamine.[21]

A psychotron, a device for administering electroshock / Source: Paul Hermans, Wikimedia Commons (CC BY-SA-3.0)

Electroconvulsive therapy (ECT)

ECT, electroconvulsive therapy, has been proven to be the most effective treatment for severe depression. Even if medications do not work, ECT can provide a solution. The treatment is done under general anesthesia. The Rijnstate Hospital Arnhem is an expert in complex psychiatry and electroconvulsive therapy (ECT).

Repetitive Transcranial Magnetic Stimulation (rTMS)

The abbreviation rTMS stands for repetitive Transcranial Magnetic Stimulation . This involves placing a coil at a specific location on your head, after which a strong magnetic field is generated, which is then converted into pulses that leave the coil of the device. These pulses can stimulate or dampen certain parts of the brain, which improves communication between the different brain areas. This form of treatment is given in the context of depression that is treatment-resistant. Treatment-resistant depression concerns patients with chronic, treatment-resistant depression who are not eligible or do not want to be eligible for ECT treatment (see below) and combination therapy of antidepressants for a sufficient period (at least 1 year) (2 treatments in accordance with the guideline) and at least 1 have had thorough psychotherapy in the past.

Deep brain stimulation / Source: Hellerhoff, Wikimedia Commons (CC BY-SA-3.0)

Deep Brain Stimulation (DBS)

Deep brain stimulation is a technique in which local areas in the brain are stimulated using electrical stimuli. Stimulation of the ventromedial prefrontal cortex is effective in 40% of treatment-resistant depressive patients for whom other treatment methods were insufficiently effective.[22] About 15% of patients with a chronic major depressive disorder respond inadequately to psychotherapy, medication or electroconvulsive therapy. In that case, DBS can offer a solution. DBS is an effective and safe treatment for treatment-resistant depression.[23]

Prognosis

Complete recovery is an exception

The longer-term prognosis of depression is less rosy than is often assumed. Following patients with depression over a longer period of time and including closely related disorders, such as anxiety disorders and bipolar disorders, shows that the course of depression is less favorable than is often thought.[24] For the majority, depression is a disabling and chronic mood disorder. Full recovery is the exception rather than the rule.

Recurrence or chronic depression

The prognosis is better if someone is treated for depression. Untreated depression usually does not go away on its own and often gets worse over time. Untreated depression increases the risk of suicide or suicide. Depression is a very serious illness that requires treatment and those who take the difficult step of seeking treatment will usually experience some degree of recovery. However, recurrence or recurrence cannot be ruled out, even after intensive and adequate treatment. Sometimes chronic depression develops. This lasts for more than 2 years.

Suicide in treatment-resistant depression

There is a high suicide risk in treatment-resistant depression. Of the people who suffer from treatment-resistant depression and who have started a new treatment after at least 2 different treatments, 1 in 20 attempts suicide every year; 10% of those attempts are actually successful.[25] It makes no difference exactly which treatment is started.

Prevention

Precautionary actions

Little is known about how to prevent depression, but exercise and avoiding alcohol and drugs can help. Frequent exercise and exercise (running) are also useful measures to prevent depression from coming back (relapse) and can improve the symptoms of mild depression. You may also be able to prevent depression by avoiding alcohol and drugs. Alcohol and drugs can contribute to depression. And its use could be a sign that you have depression.

Preventing depression from coming back

You may be able to prevent a relapse or prevent your symptoms from getting worse if you:

  • You are adherent to therapy and you take medication as prescribed. Depression often returns when you stop taking antidepressants and/or other medications prescribed by a psychiatrist.
  • Continue psychotherapy or cognitive behavioral therapy after your symptoms improve and the depression clears. Research shows that people treated with a combination of pills and talking are less likely to relapse than people treated with antidepressants alone.
  • Maintains a healthy lifestyle:
    • Eat healthy and varied.
    • Regular exercise.
    • Maintain a healthy sleep pattern with a good day and night rhythm.
    • Avoid alcohol and drugs.
  • Get help immediately as soon as you notice symptoms of depression coming back or getting worse.

 

Healthy food / Source: Oleksandra Naumenko/Shutterstock

Depression and nutrition

There is an undeniable link between depression and nutrition.

Adapted Mediterranean diet

Research shows that dietary improvements can be an effective and accessible treatment strategy for improving depressive symptoms.[26] The following foods are recommended: whole grains, fruits, vegetables, legumes, low-fat/unsweetened dairy products, raw unsalted nuts, lean red meat, chicken, fish, eggs, and olive oil. The following foods are discouraged: sweets, refined grains (such as in white bread, cookies and white pasta), fried foods, fast food, processed meats. Drinks: up to two sugar-sweetened drinks per week and up to two alcoholic drinks per day, preferably red wine. (The Nutrition Center recommends that you preferably avoid alcoholic drinks or consume a maximum of 1 drink per day. This applies to both men and women.)

The diet examined (an adapted Mediterranean diet, so-called ‘ModiMedDiet’) appears to be better than the average diet. for the following reasons, among others:

  • It is extremely low in refined carbohydrates (sugar, flour, refined grains, etc.). These foods send your blood sugar, insulin, hormones and neurotransmitters on a dangerous invisible roller coaster. This destabilizes mood and increases the risk of insulin resistance, which causes brain damage over time.
  • It contains a lot of natural fat and cholesterol, which helps the brain function better. The ModiMed diet is low in unnecessary saturated animal fats.
  • It contains animal protein sources that are rich in important brain nutrients such as iron, zinc and vitamin B12.
  • It is mainly based on healthy foods with:
    • fresh fruit and vegetables, legumes such as kidney beans and lentils
    • olive oil
    • nuts and seeds
    • fish</li

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