Clinical depression – psychotic depression
Depression is more than simply feeling unhappy or fed up for a few days.
We all go through spells of feeling down, but when you're depressed you feel persistently sad for weeks or months, rather than just a few days.
Some people still think that depression is trivial and not a genuine health condition. They're wrong. Depression is a real illness with real symptoms, and it's not a sign of weakness or something you can "snap out of" by "pulling yourself together".
The good news is that with the right treatment and support, most people can make a full recovery.
How to tell if you have depression
Depression affects people in different ways and can cause a wide variety of symptoms.
They range from lasting feelings of sadness and hopelessness, to losing interest in the things you used to enjoy and feeling very tearful. Many people with depression also have symptoms of anxiety.
There can be physical symptoms too, such as feeling constantly tired, sleeping badly, having no appetite or sex drive, and complaining of various aches and pains.
The severity of the symptoms can vary. At its mildest, you may simply feel persistently low in spirit, while at its most severe depression can make you feel suicidal and that life is no longer worth living.
Most people experience feelings of stress, sadness or anxiety during difficult times. A low mood may improve after a short time, rather than being a sign of depression.
When to see a doctor
It's important to seek help from your GP if you think you may be depressed.
If you've been feeling low for more than a few days, take this short test to if you're depressed.
Many people wait a long time before seeking help for depression, but it's best not to delay. The sooner you see a doctor, the sooner you can be on the way to recovery.
Sometimes there is a trigger for depression. Life-changing events, such as bereavement, losing your job or even having a baby, can bring it on.
People with a family history of depression are also more likely to experience it themselves.
But you can also become depressed for no obvious reason.
Find out more about the causes of depression.
Depression is quite common and affects about one in 10 of us at some point. It affects men and women, young and old.
Depression can also strike children. Studies have shown that about 4% of children aged five to 16 in the UK are anxious or depressed.
Treatment for depression involves either medication or talking treatments, or usually a combination of the two. The kind of treatment that your doctor recommends will be based on the type of depression you have.
Living with depression
Many people with depression benefit by making lifestyle changes such as getting more exercise, cutting down on alcohol, stopping smoking and eating more healthily.
Self-help measures such as reading a self-help book or joining a support group are also worthwhile.
You can read other people's experience of depression in our comments section below.
Symptoms of clinical depression
The symptoms of depression can be complex and vary widely between people. But as a general rule, if you are depressed, you feel sad, hopeless and lose interest in things you used to enjoy.
The symptoms persist for weeks or months and are bad enough to interfere with your work, social life and family life.
There are many other symptoms of depression and you're unlikely to have every one listed below.
If you experience some of these symptoms for most of the day, every day for more than two weeks, you should seek help from your GP.
Psychological symptoms include:
continuous low mood or sadness
feeling hopeless and helpless
having low self-esteem
feeling irritable and intolerant of others
having no motivation or interest in things
finding it difficult to make decisions
not getting any enjoyment out of life
feeling anxious or worried
having suicidal thoughts or thoughts of harming yourself
Physical symptoms include:
moving or speaking more slowly than usual
change in appetite or weight (usually decreased, but sometimes increased)
unexplained aches and pains
lack of energy or lack of interest in sex (loss of libido)
changes to your menstrual cycle
disturbed sleep (for example, finding it hard to fall asleep at night or waking up very early in the morning)
Social symptoms include:
not doing well at work
taking part in fewer social activities and avoiding contact with friends
neglecting your hobbies and interests
having difficulties in your home and family life
Depression can come on gradually, so it can be difficult to notice something is wrong. Many people continue to try to cope with their symptoms without realising they are ill. It can take a friend or family member to suggest something is wrong.
Doctors describe depression by how serious it is:
mild depression has some impact on your daily life
moderate depression has a significant impact on your daily life
severe depression makes it almost impossible to get through daily life – a few people with severe depression may have psychotic symptoms
Grief and depression
It can be hard to distinguish between grief and depression. They share many of the same characteristics, but there are important differences between them.
Grief is an entirely natural response to a loss, while depression is an illness.
People who are grieving find their feelings of loss and sadness come and go, but they're still able to enjoy things and look forward to the future.
In contrast, people who are depressed have a constant feeling of sadness. They don't enjoy anything and find it hard to be positive about the future.
Other types of depression
There are different types of depression, and some conditions where depression may be one of the symptoms. These include:
Postnatal depression. Some women develop depression after having a baby. Postnatal depression is treated in similar ways to other forms of depression, with talking therapies and antidepressant medicines.
Bipolar disorder is also known as "manic depression". It's where there are spells of depression and excessively high mood (mania). The depression symptoms are similar to clinical depression, but the bouts of mania can include harmful behaviour such as gambling, going on spending sprees and having unsafe sex.
Seasonal affective disorder (SAD). Also known as "winter depression", SAD is a type of depression that has a seasonal pattern usually related to winter.
There is no single cause of depression. You can develop it for different reasons and it has many different triggers.
For some, an upsetting or stressful life event – such as bereavement, divorce, illness, redundancy and job or money worries – can be the cause.
Often, different causes combine to trigger depression. For example, you may feel low after an illness and then experience a traumatic event, such as bereavement, which brings on depression.
People often talk about a "downward spiral" of events that leads to depression. For example, if your relationship with your partner breaks down, you're likely to feel low, so you stop seeing friends and family and you may start drinking more. All of this can make you feel even worse and trigger depression.
Some studies have also suggested you're more likely to get depression as you get older, and that it's more common if you live in difficult social and economic circumstances.
Most people take time to come to terms with stressful events, such as bereavement or a relationship breakdown. When these stressful events happen, you have a higher risk of becoming depressed if you stop seeing your friends and family and you try to deal with your problems on your own.
You may have a higher risk of depression if you have a longstanding or life-threatening illness, such as coronary heart disease or cancer.
Head injuries are also an often under-recognised cause of depression. A severe head injury can trigger mood swings and emotional problems.
Some people may have an underactive thyroid (hypothyroidism) resulting from problems with their immune system. In rarer cases a minor head injury can damage the pituitary gland, a pea-sized gland at the base of your brain that produces thyroid-stimulating hormones.
This can cause a number of symptoms, such as extreme tiredness and a loss of interest in sex (loss of libido), which can in turn lead to depression.
You may be more vulnerable to depression if you have certain personality traits, such as low self-esteem or being overly self-critical. This may be because of the genes you've inherited from your parents, or because of your early life experiences.
If someone else in your family has suffered from depression in the past, such as a parent or sister or brother, then it's more likely you will too.
Some women are particularly vulnerable to depression after pregnancy. The hormonal and physical changes, as well as added responsibility of a new life, can lead to postnatal depression.
Becoming cut off from your family and friends can increase your risk of depression.
Alcohol and drugs
Some people try to cope when life is getting them down by drinking too much alcohol or taking drugs. This can result in a spiral of depression.
Cannabis helps you relax, but there is evidence that it can bring on depression, especially in teenagers.
And don't be tempted to drown your sorrows with a drink. Alcohol is categorised as a "strong depressant" and actually makes depression worse.
Depression can be triggered by more than one factor
Diagnosing clinical depression
If you experience symptoms of depression for most of the day, every day for more than two weeks, you should seek help from your GP.
It is especially important to speak to your GP if you experience:
symptoms of depression that are not improving
your mood affects your work, other interests, and relationships with your family and friends
thoughts of suicide or self-harm
Sometimes, when people are depressed they find it hard to imagine that treatment can actually help. But the sooner you seek treatment, the sooner your depression will lift.
There are no physical tests for depression, though your GP may examine you and do some urine or blood tests to rule out other conditions that have similar symptoms, such as an underactive thyroid.
The main way in which your GP will tell if you have depression is by asking you lots of questions about your general health and how the way you are feeling is affecting you mentally and physically.
Try to be as open as you can be with the doctor. Describing your symptoms and how they are affecting you will really help your GP understand if you have depression and how severe it is.
Any discussion you have with your GP will be confidential. Your GP will only ever break this rule if there's a significant risk of harm to either yourself or others, and if informing a family member or carer would reduce that risk.
Treating clinical depression
Treatment for depression usually involves a combination of medicines, talking therapies and self-help.
The kind of treatment that your doctor recommends will be based on the type of depression you have. Below is a short description of the types of treatment your doctor may recommend.
wait and see – if you're diagnosed with mild depression, your depression may improve by itself. In this case, you'll simply be seen again by your GP after two weeks to monitor your progress. This is known as watchful waiting.
exercise – there is evidence that exercise may help depression and it is one of the main treatments if you have mild depression. Your GP may refer you to a qualified fitness trainer for an exercise scheme, or you can find out more about starting exercise here. Read more about exercise for depression.
self-help groups – talking through your feelings can be helpful. You could talk either to a friend or relative, or you can ask your GP to suggest a local self-help group. Find out more about depression support groups. Your GP may also recommend self-help books and online cognitive behavioural therapy (CBT).
Mild to moderate depression
talking therapy – if you have mild depression that isn't improving, or you have moderate depression, your GP may recommend a talking treatment (a type of psychotherapy). There are different types of talking therapy for depression, including cognitive behavioural therapy (CBT) and counselling. Your GP can refer you for talking treatment or in some parts of the country you might be able to refer yourself.
Moderate to severe depression
antidepressants – antidepressants are tablets that treat the symptoms of depression. There are almost 30 different kinds of antidepressant. They have to be prescribed by a doctor, usually for depression that is moderate or severe.
combination therapy – your GP may recommend that you take a course of antidepressants plus talking therapy, particularly if your depression is quite severe. A combination of an antidepressant and CBT usually works better than having just one of these treatments.
mental health teams – if you have severe depression, you may be referred to a mental health team made up of psychologists, psychiatrists, specialist nurses and occupational therapists. These teams often provide intensive specialist talking treatments as well as prescribed medication.
You can see a summary of the pros and cons of these treatments, which allows you to easily compare your options.
Living with clinical depression
There are some key steps you can take to lift your mood and help your recovery from depression.
Take your medication
It is important to take your medication as prescribed, even if you start to feel better.
If you stop your medication too soon, you could have a relapse of your depression. If you have any questions or concerns about the medication you're taking, talk to your doctor or pharmacist.
It may help to read the information leaflet that comes with your medication to find out about possible interactions with other drugs or supplements. Check with your doctor first if you plan to take any over-the-counter remedies such as painkillers, or any nutritional supplements. These can sometimes interfere with antidepressants.
Exercise and diet
Exercise and a healthy diet can make a tremendous difference to how quickly you recover from depression. And they will both improve your general health, too.
Research suggests that exercise may be as effective as antidepressants at reducing depression symptoms.
Being physically active can lift your mood, reduce stress and anxiety, boost the release of endorphins (your body's feel-good chemicals) and improve self-esteem. Also, exercising may be a good distraction from negative thoughts, and it can improve social interaction.
It also helps your mood to have a healthy diet. In fact, eating healthily seems to be just as important for maintaining your mental health as it is for preventing physical health problems.
boosting your mood, coping with stress, anxiety or depression, or simply improving your overall emotional wellbeing, in the Moodzone.
You could also try this five-minute audio guide to coping with low mood and depression.
It can be easy to rush through life without stopping to notice much. Paying more attention to the present moment – to your own thoughts and feelings, and to the world around you – can improve your mental wellbeing. Some people call this awareness 'mindfulness', and you can take steps to develop it in your own life.
The National Institute for Health and Clinical Excellence (NICE) recommends 'mindfulness based cognitive therapy' for people who are currently well but have experienced three or more previous episodes of depression. It may help to prevent a future episode of depression. Read the NICE 2009 guidelines on Depression in Adults.
Some people who have severe clinical depression will also experience hallucinations and delusional thinking, the symptoms of psychosis.
Depression with psychosis is known as psychotic depression.
What are the symptoms of severe depression?
Having severe clinical depression means feeling sad and hopeless for most of the day, practically every day, and having no interest in anything. Getting through the day feels almost impossible.
Other typical symptoms of severe depression are:
loss of pleasure in things
changes in appetite
feeling worthless and guilty
being unable to concentrate or being indecisive
thoughts of death or suicide
What are the symptoms of psychosis?
Having moments of psychosis (psychotic episodes) means experiencing:
delusions – thoughts or beliefs that are unlikely to be true
when a person hears (and in some cases feels, smells, sees or tastes) things that aren't there; a common hallucination is hearing voices.
The delusions and hallucinations almost always reflect the person's deeply depressed mood – for example, they may become convinced they're to blame for something, or that they've committed a crime.
"Psychomotor agitation" is also common – this means not being able to relax or sit still, and constantly fidgeting.
Or, at the other extreme, a person with psychotic depression may have "psychomotor retardation", where both their thoughts and physical movements slow down.
People with psychotic depression are at greater risk than normal of thinking about suicide.
What's the cause?
The cause of psychotic depression is not fully understood. What we do know is that there's no single cause of depression and it has many different triggers.
For some, stressful life events such as bereavement, divorce, serious illness or financial worries can be the cause.
Genes probably play a part, as severe depression can run in families, although it's not known why some people also develop psychosis.
Many people with psychotic depression will have experienced adversity in childhood, such as a traumatic event.
Learn more about the causes of clinical depression.
How is it treated?
Treatment for psychotic depression involves:
medication – a combination of antipsychotics and antidepressantscan help relieve the symptoms of psychosis
psychological therapies – the one-to-one talking therapycognitive behavioural therapy (CBT) has proved successful in helping some people with psychosis
social support – support with social needs, such as education, employment or accommodation
The patient may need to stay in hospital for a short period while they're receiving this treatment.
Sometimes electroconvulsive therapy (ECT) may be recommended if the patient has severe depression and other treatments, including antidepressants, haven't worked.
Treatment is usually very effective, although patients may need to be continuously monitored in follow-up appointments.
Getting help for others
People with psychosis are often unaware that they're thinking and acting strangely.
Because of this lack of insight, it's often down to the friends, relatives or carers of a person affected by psychosis to seek help for them.
If you're concerned about someone you know and think they may have psychosis, you could contact their social worker or community mental health nurse if they've previously been diagnosed with a mental health condition.
If this is the first time they've shown symptoms, contact their GP or take them to A&E.
If you think the person’s symptoms are placing them at possible risk of harm you can:
take them to the nearest accident and emergency (A&E)department, if they agree
call their GP or local out-of-hours GP
call 999 and ask for an ambulance
Support and advice
More information on psychosis
Supporting someone who has experienced psychosis
Having psychosis could affect your ability to drive.
If you have been diagnosed with psychotic depression, it's your legal obligation to tell the Driver and Vehicle Licensing Agency (DVLA) as it could affect your driving ability.
GOV.UK provides details about telling the DVLA about a medical condition.