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Mental Health Conditions: Depression and Anxiety

What Is Depression?

Depression is more than just feeling down or having a bad day. When a sad mood lasts for a long time and interferes with normal, everyday functioning, you may be depressed. Symptoms of depression include:1

Feeling sad or anxious often or all the time
Not wanting to do activities that used to be fun
Feeling irritable‚ easily frustrated‚ or restless
Having trouble falling asleep or staying asleep
Waking up too early or sleeping too much
Eating more or less than usual or having no appetite
Experiencing aches, pains, headaches, or stomach problems that do not improve with treatment
Having trouble concentrating, remembering details, or making decisions
Feeling tired‚ even after sleeping well
Feeling guilty, worthless, or helpless
Thinking about suicide or hurting yourself
The following information is not intended to provide a medical diagnosis of major depression and cannot take the place of seeing a mental health professional. If you think you are depressed‚ talk with your doctor or a mental health professional immediately. This is especially important if your symptoms are getting worse or affecting your daily activities.

What Causes Depression?

The exact cause of depression is unknown. It may be caused by a combination of genetic, biological, environmental, and psychological factors.2 Everyone is different‚ but the following factors may increase a person’s chances of becoming depressed:1

Having blood relatives who have had depression
Experiencing traumatic or stressful events, such as physical or sexual abuse, the death of a loved one, or financial problems
Going through a major life change‚ even if it was planned
Having a medical problem, such as cancer, stroke, or chronic pain
Taking certain medications. Talk to your doctor if you have questions about whether your medications might be making you feel depressed.
Using alcohol or drugs

FROM CDS

What Are the Treatments for Depression?

Therapy. Many people benefit from psychotherapy—also called therapy or counseling.7,8 Most therapy lasts for a short time and focuses on thoughts‚ feelings‚ and issues that are happening in your life now. In some cases‚ understanding your past can help‚ but finding ways to address what is happening in your life now can help you cope and prepare you for challenges in the future.With therapy, you’ll work with your therapist to learn skills to help you cope with life, change behaviors that are causing problems‚ and find solutions. Do not feel shy or embarrassed about talking openly and honestly about your feelings and concerns. This is an important part of getting better.Some common goals of therapy include:

Getting healthier
Quitting smoking and stopping drug and alcohol use
Overcoming fears or insecurities
Coping with stress
Making sense of past painful events
Identifying things that worsen your depression
Having better relationships with family and friends
Understanding why something bothers you and creating a plan to deal with it

Medication. Many people with depression find that taking prescribed medications called antidepressants can help improve their mood and coping skills. Talk to your doctor about whether they are right for you. If your doctor writes you a prescription for an antidepressant‚ ask exactly how you should take the medication. If you are already using nicotine replacement therapy or another medication to help you quit smoking, be sure to let your doctor know. Several antidepressant medications are available‚ so you and your doctor have options to choose from. Sometimes it takes several tries to find the best medication and the right dose for you, so be patient. Also be aware of the following important information:

When taking these medications‚ it is important to follow the instructions on how much to take. Some people start to feel better a few days after starting the medication‚ but it can take up to 4 weeks to feel the most benefit. Antidepressants work well and are safe for most people‚ but it is still important to talk with your doctor if you have side effects. Side effects usually do not get in the way of daily life‚ and they often go away as your body adjusts to the medication.
Don’t stop taking an antidepressant without first talking to your doctor. Stopping your medicine suddenly can cause symptoms or worsen depression. Work with your doctor to safely adjust how much you take.

Some antidepressants may cause risks during pregnancy. Talk with your doctor if you are pregnant or might be pregnant, or if you are planning to become pregnant.
Antidepressants cannot solve all of your problems. If you notice that your mood is getting worse or if you have thoughts about hurting yourself‚ it is important to call your doctor right away.
Quitting smoking will not interfere with your mental health treatment or make your depression worse. In fact, research shows that quitting smoking can actually improve your mental health in the long run.

Black Mental Health-The suicide rate among Black youth has been found to be increasing faster than any other racial/ethnic group. Black adults living below the poverty line are more than twice as likely to report serious psychological distress than those with more financial security. Additionally, members of the Black community face structural racism, leading to barriers to access for the care and treatment they need. Only one in three Black adults who need mental health care receive it.

Panic Disorder: When Fear Overwhelms

source: NIMH

Do you sometimes have sudden attacks of anxiety and overwhelming fear that last for several minutes? Maybe your heart pounds, you sweat, and you feel like you can’t breathe or think clearly. Do these attacks occur at unpredictable times with no apparent trigger, causing you to worry about the possibility of having another one at any time?

An untreated panic disorder can affect your quality of life and lead to difficulties at work or school. The good news is panic disorder is treatable. Learn more about the symptoms of panic disorder and how to find help.

What is panic disorder?

People with panic disorder have frequent and unexpected panic attacks. These attacks are characterized by a sudden wave of fear or discomfort or a sense of losing control even when there is no clear danger or trigger. Not everyone who experiences a panic attack will develop panic disorder.

Panic attacks often include physical symptoms that might feel like a heart attack, such as trembling, tingling, or rapid heart rate. Panic attacks can occur at any time. Many people with panic disorder worry about the possibility of having another attack and may significantly change their life to avoid having another attack. Panic attacks can occur as frequently as several times a day or as rarely as a few times a year.

Panic disorder often begins in the late teens or early adulthood. Women are more likely than men to develop panic disorder.

What are the signs and symptoms of panic disorder?

People with panic disorder may have:

Sudden and repeated panic attacks of overwhelming anxiety and fear
A feeling of being out of control, or a fear of death or impending doom during a panic attack
An intense worry about when the next panic attack will happen
A fear or avoidance of places where panic attacks have occurred in the past
Physical symptoms during a panic attack, such as:
Pounding or racing heart
Sweating
Chills
Trembling
Difficulty breathing
Weakness or dizziness
Tingly or numb hands
Chest pain
Stomach pain or nausea

What causes panic disorder?

Panic disorder sometimes runs in families, but no one knows for sure why some family members have it while others don’t. Researchers have found that several parts of the brain and certain biological processes may play a crucial role in fear and anxiety. Some researchers think panic attacks are like “false alarms” where our body’s typical survival instincts are active either too often, too strongly, or some combination of the two. For example, someone with panic disorder might feel their heart pounding and assume they’re having a heart attack. This may lead to a vicious cycle, causing a person to experience panic attacks seemingly out of the blue, the central feature of panic disorder. Researchers are studying how the brain and body interact in people with panic disorder to create more specialized treatments. In addition, researchers are looking at the ways stress and environmental factors play a role in the disorder.

How is panic disorder treated?

If you’re experiencing symptoms of panic disorder, talk to a health care provider. After discussing your history, a health care provider may conduct a physical exam to ensure that an unrelated physical problem is not causing your symptoms. A health care provider may refer you to a mental health professional, such as a psychiatrist, psychologist, or clinical social worker. The first step to effective treatment is to get a diagnosis, usually from a mental health professional.

Panic disorder is generally treated with psychotherapy (sometimes called “talk therapy”), medication, or both. Speak with a health care provider about the best treatment for you.

Psychotherapy

Cognitive behavioral therapy (CBT), a research-supported type of psychotherapy, is commonly used to treat panic disorder. CBT teaches you different ways of thinking, behaving, and reacting to the feelings that happen during or before a panic attack. The attacks can become less frequent once you learn to react differently to the physical sensations of anxiety and fear during a panic attack.

Exposure therapy is a common CBT method that focuses on confronting the fears and beliefs associated with panic disorder to help you engage in activities you have been avoiding. Exposure therapy is sometimes used along with relaxation exercises.

For more information on psychotherapy, visit the National Institute of Mental Health (NIMH) psychotherapies webpage.

Medication

Health care providers may prescribe medication to treat panic disorder. Different types of medication can be effective, including:

Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)
Beta-blockers

Anti-anxiety medications, such as benzodiazepines
SSRI and SNRI antidepressants are commonly used to treat depression, but they also can help treat the symptoms of panic disorder. They may take several weeks to start working. These medications also may cause side effects, such as headaches, nausea, or difficulty sleeping. These side effects are usually not severe, especially if the dose starts off low and is increased slowly over time. Talk to your health care provider about any side effects that you may experience.

Beta-blockers can help control some of the physical symptoms of panic disorder, such as rapid heart rate, sweating, and tremors. Although health care providers do not commonly prescribe beta-blockers for panic disorder, the medication may be helpful in certain situations that precede a panic attack.

Benzodiazepines, which are anti-anxiety sedative medications, can be very effective in rapidly decreasing panic attack symptoms. However, some people build up a tolerance to these medications and need higher and higher doses to get the same effect. Some people even become dependent on them. Therefore, a health care provider may prescribe them only for brief periods of time if you need them.

Both psychotherapy and medication can take some time to work. Many people try more than one medication before finding the best one for them. A health care provider can work with you to find the best medication, dose, and duration of treatment for you. A healthy lifestyle also can help combat panic disorder. Make sure to get enough sleep and exercise, eat a healthy diet, and turn to family and friends who you trust for support. To learn more ways to take care of your mental health, visit NIMH’s Caring for Your Mental Health webpage.

For more information about medications used to treat panic disorder, visit NIMH’s Mental Health Medications webpage. Visit the U.S. Food and Drug Administration (FDA) website for the latest warnings, patient medication guides, and information on newly approved medications.

Mental Disorders and Related Topics

Anxiety Disorders
Attention-Deficit/Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Bipolar Disorder
Borderline Personality Disorder
Depression
Disruptive Mood Dysregulation Disorder
Eating Disorders
HIV/AIDS and Mental Health
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Schizophrenia
Substance Use and Co-Occurring Mental Disorders
Suicide Prevention (Disponible en español)
Traumatic Events

Treatments and Therapies

Brain Stimulation Therapies
Caring for Your Mental Health (Disponible en español)
Help for Mental Illnesses (Disponible en español)
Medications
Psychotherapies
Technology and the Future of Mental Health Treatment

Brain Stimulation Therapies

Overview

Brain stimulation therapies can play a role in treating certain mental disorders. Brain stimulation therapies involve activating or inhibiting the brain directly with electricity. The electricity can be given directly by electrodes implanted in the brain, or noninvasively through electrodes placed on the scalp. The electricity can also be induced by using magnetic fields applied to the head. While these types of therapies are less frequently used than medication and psychotherapies, they hold promise for treating certain mental disorders that do not respond to other treatments.

Electroconvulsive therapy is the best studied brain stimulation therapy and has the longest history of use. Other stimulation therapies discussed here are newer, and in some cases still experimental methods. These include:

vagus nerve stimulation (VNS)

repetitive transcranial magnetic stimulation (rTMS)
magnetic seizure therapy (MST)
deep brain stimulation (DBS)

A treatment plan may also include medication and psychotherapy. Choosing the right treatment plan should be based on a person’s individual needs and medical situation, and under a doctor’s care.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) uses an electric current to treat serious mental disorders. This type of therapy is usually considered only if a patient’s illness has not improved after other treatments (such as antidepressant medication or psychotherapy) are tried, or in cases where rapid response is needed (as in the case of suicide risk and catatonia, for example).

ECT: Why it’s done

ECT is most often used to treat severe, treatment-resistant depression, but it may also be medically indicated in other mental disorders, such as bipolar disorder or schizophrenia. It also may be used in life-threatening circumstances, such as when a patient is unable to move or respond to the outside world (e.g., catatonia), is suicidal, or is malnourished as a result of severe depression.

ECT can be effective in reducing the chances of relapse when patients undergo follow-up treatments. Two major advantages of ECT over medication are that ECT begins to work quicker, often starting within the first week, and older individuals respond especially quickly.

ECT: How it works
Before ECT is administered, a person is sedated with general anesthesia and given a medication called a muscle relaxant to prevent movement during the procedure. An anesthesiologist monitors breathing, heart rate and blood pressure during the entire procedure, which is conducted by a trained medical team, including physicians and nurses. During the procedure:

Electrodes are placed at precise locations on the head.

Through the electrodes, an electric current passes through the brain, causing a seizure that lasts generally less than one minute. Because the patient is under anesthesia and has taken a muscle relaxant, it is not painful and the patient cannot feel the electrical impulses.
Five to ten minutes after the procedure ends, the patient awakens. He or she may feel groggy at first as the anesthesia wears off. But after about an hour, the patient usually is alert and can resume normal activities.

A typical course of ECT is administered about three times a week until the patient’s depression improves (usually within 6 to 12 treatments). After that, maintenance ECT treatment is sometimes needed to reduce the chances that symptoms will return. ECT maintenance treatment varies depending on the needs of the individual, and may range from one session per week to one session every few months. Frequently, a person who undergoes ECT also takes antidepressant medication or a mood stabilizing medication.

ECT Side Effects

The most common side effects associated with ECT include:

headache
upset stomach
muscle aches
memory loss

Some people may experience memory problems, especially of memories around the time of the treatment. Sometimes the memory problems are more severe, but usually they improve over the days and weeks following the end of an ECT course.

Research has found that memory problems seem to be more associated with the traditional type of ECT called bilateral ECT, in which the electrodes are placed on both sides of the head.

In unilateral ECT, the electrodes are placed on just one side of the head—typically the right side because it is opposite the brain’s learning and memory areas. Unilateral ECT has been found to be less likely to cause memory problems and therefore is preferred by many doctors, patients and families.

Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) works through a device implanted under the skin that sends electrical pulses through the left vagus nerve, half of a prominent pair of nerves that run from the brainstem through the neck and down to each side of the chest and abdomen. The vagus nerves carry messages from the brain to the body’s major organs (e.g. heart, lungs and intestines) and to areas of the brain that control mood, sleep, and other functions.

VNS: Why it’s done

VNS was originally developed as a treatment for epilepsy. However, scientists noticed that it also had favorable effects on mood, especially depressive symptoms. Using brain scans, scientists found that the device affected areas of the brain that are involved in mood regulation. The pulses appeared to alter the levels of certain neurotransmitters (brain chemicals) associated with mood, including serotonin, norepinephrine, GABA and glutamate.

In 2005, the U.S. Food and Drug Administration (FDA) approved VNS for use in treating treatment-resistant depression in certain circumstances:

If the patient is 18 years of age or over; and
If the illness has lasted two years or more; and
if it is severe or recurrent; and
if the depression has not eased after trying at least four other treatments

According to the FDA, it is not intended to be a first-line treatment, even for patients with severe depression. And, despite FDA approval, VNS remains an infrequently used because results of early studies testing its effectiveness for major depression were mixed. But a newer study, which pooled together findings from only controlled clinical trials, found that 32% of depressed people responded to VSN and 14% had a full remission of symptoms after being treated for nearly 2 years.

VNS: How it works

A device called a pulse generator, about the size of a stopwatch, is surgically implanted in the upper left side of the chest. Connected to the pulse generator is an electrical lead wire, which is connected from the generator to the left vagus nerve.

Typically, 30-second electrical pulses are sent about every five minutes from the generator to the vagus nerve. The duration and frequency of the pulses may vary depending on how the generator is programmed. The vagus nerve, in turn, delivers those signals to the brain. The pulse generator, which operates continuously, is powered by a battery that lasts around 10 years, after which it must be replaced. Normally, people do not feel pain or any other sensations as the device operates.

The device also can be temporarily deactivated by placing a magnet over the chest where the pulse generator is implanted. A person may want to deactivate it if side effects become intolerable, or before engaging in strenuous activity or exercise because it may interfere with breathing. The device reactivates when the magnet is removed.

Please Note: VNS should only be prescribed and monitored by doctors who have specific training and expertise in the management of treatment-resistant depression and the use of this device.

VNS treatment is intended to reduce symptoms of depression. It may be several months before the patient notices any benefits and not all patients will respond to VNS. It is important to remember that VNS is intended to be given along with other traditional therapies, such as medications, and patients should not expect to discontinue these other treatments, even with the device in place.

VNS: Side Effects

VNS is not without risk. There may be complications such as infection from the implant surgery, or the device may come loose, move around or malfunction, which may require additional surgery to correct. Some patients have no improvement in symptoms and some actually get worse.

Other potential side effects include:

Voice changes or hoarseness
Cough or sore throat
Neck pain
Discomfort or tingling in the area where the device is implanted
Breathing problems, especially during exercise
Difficulty swallowing
Long-term side effects are unknown.

Repetitive Transcranial Magnetic Stimulation

Repetitive transcranial magnetic stimulation (rTMS) uses a magnet to activate the brain. First developed in 1985, rTMS has been studied as a treatment for depression, psychosis, anxiety, and other disorders.

Unlike ECT, in which electrical stimulation is more generalized, rTMS can be targeted to a specific site in the brain. Scientists believe that focusing on a specific site in the brain reduces the chance for the types of side effects associated with ECT. But opinions vary as to what site is best.

rTMS: Why it’s done

In 2008, rTMS was approved for use by the FDA as a treatment for major depression for patients who do not respond to at least one antidepressant medication in the current episode. It is also used in other countries as a treatment for depression in patients who have not responded to medications and who might otherwise be considered for ECT.

The evidence supporting rTMS for depression was mixed until the first large clinical trial, funded by NIMH, was published in 2010. The trial found that 14% achieved remission with rTMS compared to 5% with an inactive (sham) treatment. After the trial ended, patients could enter a second phase in which everyone, including those who previously received the sham treatment, was given rTMS. Remission rates during the second phase climbed to nearly 30%. A sham treatment is like a placebo, but instead of being an inactive pill, it’s an inactive procedure that mimics real rTMS.

rTMS: How it works

A typical rTMS session lasts 30 to 60 minutes and does not require anesthesia.

During the procedure:

An electromagnetic coil is held against the forehead near an area of the brain that is thought to be involved in mood regulation.
Then, short electromagnetic pulses are administered through the coil. The magnetic pulses easily pass through the skull, and causes small electrical currents that stimulate nerve cells in the targeted brain region.

Because this type of pulse generally does not reach further than two inches into the brain, scientists can select which parts of the brain will be affected and which will not be. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan. Generally, the person feels a slight knocking or tapping on the head as the pulses are administered.

Not all scientists agree on the best way to position the magnet on the patient’s head or give the electromagnetic pulses. They also do not yet know if rTMS works best when given as a single treatment or combined with medication and/or psychotherapy. More research is underway to determine the safest and most effective uses of rTMS.

rTMS: Side Effects

Sometimes a person may have discomfort at the site on the head where the magnet is placed. The muscles of the scalp, jaw or face may contract or tingle during the procedure. Mild headaches or brief lightheadedness may result. It is also possible that the procedure could cause a seizure, although documented incidences of this are uncommon. Two large-scale studies on the safety of rTMS found that most side effects, such as headaches or scalp discomfort, were mild or moderate, and no seizures occurred.Because the treatment is relatively new, however, long-term side effects are unknown.

Magnetic Seizure Therapy

MST: How it works

Magnetic seizure therapy (MST) borrows certain aspects from both ECT and rTMS. Like rTMS, MST uses magnetic pulses instead of electricity to stimulate a precise target in the brain. However, unlike rTMS, MST aims to induce a seizure like ECT. So the pulses are given at a higher frequency than that used in rTMS. Therefore, like ECT, the patient must be anesthetized and given a muscle relaxant to prevent movement. The goal of MST is to retain the effectiveness of ECT while reducing its cognitive side effects.

MST is in the early stages of testing for mental disorders, but initial results are promising. A recent review article that examined the evidence from eight clinical studies found that MST triggered remission from major depression or bipolar disorder in 30-40% of individuals.

MST: Side Effects

Like ECT, MST carries the risk of side effects that can be caused by anesthesia exposure and the induction of a seizure. Studies in both animals and humans have found that MST produces

fewer memory side effects
shorter seizures
allows for a shorter recovery time than ECT
Deep Brain Stimulation
artist depiction of deep brain stimulation

Deep brain stimulation (DBS) was first developed as a treatment for Parkinson’s disease to reduce tremor, stiffness, walking problems and uncontrollable movements. In DBS, a pair of electrodes is implanted in the brain and controlled by a generator that is implanted in the chest. Stimulation is continuous and its frequency and level are customized to the individual.

DBS has been studied as a treatment for depression or obsessive compulsive disorder (OCD). Currently, there is a Humanitarian Device Exemption for the use of DBS to treat OCD, but its use in depression remains only on an experimental basis. A review of all 22 published studies testing DBS for depression found that only three of them were of high quality because they not only had a treatment group but also a control group which did not receive DBS. The review found that across the studies, 40-50% of people showed receiving DBS greater than 50% improvement.

DBS: How it works
DBS requires brain surgery. The head is shaved and then attached with screws to a sturdy frame that prevents the head from moving during the surgery. Scans of the head and brain using MRI are taken. The surgeon uses these images as guides during the surgery. Patients are awake during the procedure to provide the surgeon with feedback, but they feel no pain because the head is numbed with a local anesthetic and the brain itself does not register pain.

Once ready for surgery, two holes are drilled into the head. From there, the surgeon threads a slender tube down into the brain to place electrodes on each side of a specific area of the brain. In the case of depression, the first area of the brain targeted by DBS is called Area 25, or the subgenual cingulate cortex. This area has been found to be overactive in depression and other mood disorders. But later research targeted several other areas of the brain affected by depression. So DBS is now targeting several areas of the brain for treating depression. In the case of OCD, the electrodes are placed in an area of the brain (the ventral capsule/ventral striatum) believed to be associated with the disorder.

After the electrodes are implanted and the patient provides feedback about their placement, the patient is put under general anesthesia. The electrodes are then attached to wires that are run inside the body from the head down to the chest, where a pair of battery-operated generators are implanted. From here, electrical pulses are continuously delivered over the wires to the electrodes in the brain. Although it is unclear exactly how the device works to reduce depression or OCD, scientists believe that the pulses help to “reset” the area of the brain that is malfunctioning so that it works normally again.

DBS Side Effects
DBS carries risks associated with any type of brain surgery. For example, the procedure may lead to:

Bleeding in the brain or stroke
Infection
Disorientation or confusion
Unwanted mood changes
Movement disorders
Lightheadedness
Trouble sleeping
Because the procedure is still being studied, other side effects not yet identified may be possible. Long-term benefits and side effects are unknown.

Suicide Research

Suicide is a significant global public health problem. Formed in November 2019, the Suicide Research Team leads NIMH’s suicide research activities and coordinates outreach initiatives that engage key agencies and stakeholders supporting research and other efforts to help prevent suicide.

The team’s work focuses on areas that align with the National Strategy for Suicide Prevention and significantly impact the Institute’s commitment to reducing the suicide rate by 20% by 2025. This includes activities like advancing suicide prevention research in health care settings. The team also focuses on potential increases in suicide-associated risks due to the COVID-19 pandemic (for example, distress associated with unemployment) and increases in suicide risk for underserved populations. The team’s initiatives are continually evolving to meet newer and emerging priorities, such as concerning trends in youth suicide, especially among Black youth.

The Suicide Research Team helps develop suicide-related workshops and funding opportunities to address suicide prevention research gaps. Topics range from suicide etiology (for example, social isolation; sleep problems) and risk identification (for example, risk algorithms from electronic medical records) to implementing practical and scalable interventions in a variety of settings, including health care, education, and criminal justice systems that serve at-risk populations.