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Understanding Depression

Ask-the-Expert: Understanding Depression



By Dr. Alison Hwong
Alison Hwong, MD, PhD is an Assistant Professor of Psychiatry at Stanford and the VA Palo Alto. She earned her MD and PhD in Health Policy at Harvard University, completed adult psychiatry residency at UCSF, and was a postdoctoral fellow in the UCSF National Clinician Scholars Program. Her research focuses on health disparities for people living with mental illness.

Q: What is depression? What are the symptoms of depression?
A: Let’s meet with Mr. Chen. Ever since his wife died 2 years ago, Dr. Chen hasn’t felt like himself. He said, “I have trouble sleeping, have low energy and don’t want to go out anymore. I feel like a burden on my children.” Is this normal aging, or normal grief, or is it possible that Mr. Chen has depression?

All of us will feel sad sometimes, but depression is more than just sadness. Depression is two weeks or more of several of these symptoms, and it can lead to severe problems with work, school, and being with friends and family. And people can’t just snap out of depression, they need to seek support to help with depression. Some of the symptoms to look out for include changes in sleep, changes in appetite, low energy, isolating from friends and family, feeling guilty or lacking hope, having trouble concentrating, and sometimes increased use of alcohol or other drugs. People with more severe depression may have thoughts of death or not feel like life is worth living. Not everyone will have all these symptoms and there are several types of depression.

Patient Health Questionnaire-9 (PHQ-9) is a 9-question questionnaire for depression screening. The Chinese version is available on Chinese Health Initiative website.

I’ve seen mostly seniors and older adults in my clinic, and depression in older adults is common. Up to one in five older adults has depression. But depression might look different in older adults compared to children and younger adults. And depression can also look different in different cultural settings or communities. Older adults with depression may find that their memory is worse. They may have problems with physical symptoms like backaches, headaches, stomach pains, and dizziness. Older adults might find themselves crying often or feeling numb. And they may feel like a burden on others.

Q: Why does depression occur?
A: There are several factors that can contribute to why people become depressed. There are genetic factors, so as a family history of depression increases your risk of developing depression. Having a parent or grandparent with depression doubles the risk that you might develop depression. Also, an imbalance in neurotransmitters, which are chemical signals in the brain, appears to contribute to depression. And people with chronic pain, cancer, heart disease, and other physical health conditions have higher rates of depression. Women experience depression more than men, so hormones appear to play a role. And stress and poor nutrition are also related to developing depression. There are also a few subtypes of depression. Postpartum depression affects women after giving birth. And seasonal affective disorder is a type of depression in the dark winter months. These involve hormonal changes and sleep-wake cycle changes. These also involve different treatments than general major depression. I want to emphasize that depression is not about willpower, but there is a biological basis, and we can see that brain circuits look different in people while they’re depressed.

Q: Is depression common?
A: Depression is very common. In 2023, 29% of Americans had experienced depression in their lifetime. And 17.8% of people are currently depressed or being treated for depression in 2023. And the COVID-19 pandemic contributed to rising depression rates. It seems like social isolation and loneliness related to COVID-19 pandemic contributed to the rise in depression and anxiety.

Depression can affect anyone. Male, female, young, senior, doesn’t matter what your race or ethnicity is, depression has no bounds. In the United States, 6.1% of the population identifies as Asian American or Pacific Islander and 15% had a mental illness in the last year. And that’s over 2.9 million people in the US. That is more than all the dentists and postsecondary teachers and lawyers in the country. Fortunately, there are lots of effective treatments for depression.

Q: How is depression diagnosed?
A: If you’re concerned about yourself or a loved one, the first step is to see your general practitioner or primary care provider. You can tell them you haven’t been feeling well and that you’re concerned you might be depressed. Just as they might do a check for high blood pressure or diabetes, they may start by doing a physical exam and ordering lab tests. The labs can help rule out medical causes of depression, like a vitamin deficiency or a thyroid problem. They’ll also ask you questions about your mental and emotional well-being. If it could help to bring a family member or a friend who can share how you’re doing, that can be very helpful. For Mr. Chen, the doctor would need to first rule out medical causes for depression, and then would ask him about his sleep, appetite, energy, and mood.

Q: What are treatments for depression?
A: There are several effective treatments for depression. These include medications, therapy, and self-help or behavior changes. If you’re very ill, it might be necessary to come stay at the hospital for treatment. These are the most common treatments for mild to moderate depression. For severe depression, or depression that does not improve with these treatments, there are other treatments that involve treating the brain circuits through different kinds of electrical stimulation.

The most common medications are called antidepressants. There are several different kinds and long names for these medications. This is good news because there are many options, so if the first one doesn’t work well, you can try a different one. The most common antidepressant is called an SSRI, or selective serotonin reuptake inhibitor. And serotonin is a major neurotransmitter in the brain, involved in depression. There are other antidepressants that affect different neurotransmitters, such as norepinephrine or monoamines (SNRIs, MAOIs, TCAs). Treatment is not just one size fits all. It's tailored to how your brain and body respond.

The second category of treatment is therapy. Talk therapy is a way to talk to a trained professional about how you’re feeling, thinking, and acting. There are therapies that focus on problem solving. And other therapies focus on understanding how your thoughts, feelings, and behaviors are connected. And another type of therapy focuses on how you were raised in your family and childhood, and how that affects you as an adult. A therapist can help coach you to make changes in your life and will listen to you without judgment. You can meet with a therapist one on one, or as a couple, like with your spouse, or as a family, depending on the problem. And there’s lots of science studying the effectiveness of therapy for depression and finding therapy and medication beneficial for treating depression.

There are several complementary medicine approaches that also can be helpful for depression. There are studies finding benefits of acupuncture, meditation, tai chi, yoga, and qigong. There’s a study that found brain changes for people with depression who do tai chi and take medications. So tai chi seems to help the brain form healthy connections. It’s also helpful to spend time outdoors, in nature, in sunlight, to help with sleeping and wakefulness, to get regular exercise, to eat a balanced diet, and to spend time with friends and family.

I think of these as three legs of a stool for depression treatment. One leg is medications, another leg is therapy, and the third leg is the lifestyle and other behavioral changes.

Q: When to seek professional help and where to go?
A: You can go talk to your primary care provider as a first step. At El Camino Health, we have outpatient services, therapy and medications, and inpatient care through the Mental Health and Addiction Services. You can also check out some of the tips and resources CHI has compiled for professional help and resources, and the Mental Health Association for Chinese Communities. Finally, there is a new crisis phone number, 988. Instead of calling 911 for police, you can call 988 for mental health crisis and talk to someone for help. It is a national crisis line that you can dial that anywhere in the United States.

Watch the recording of this bilingual webinar

We are grateful to Dr. and Mrs. Peter Fung for their generous support of this medical column.

Learn more about the Chinese Health Initiative.

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