Most people experience some symptoms of depressed mood at some time in their lives, because depressive feelings like sadness and helplessness can be part of a normal reaction to loss or undue stress or feelings of rejection, loneliness or failure. But most depressive feelings are transient; they go away when the immediate stressor goes away, or when some happier events occur, or when our natural resilience carries us back to our normal mood.

About seven percent of adults, however, experience what we call a Major Depressive Episode, which includes multiple symptoms persisting for at least two weeks, and usually for several months. Adults between 18 and 25, and adolescent girls, are most vulnerable to a major depressive episode, but people of all ages, including young children, can experience serious depression. Over half of people with a Major Depression experience severe symptoms and impairment. Depression is, as is well known, the most common cause of suicide, and rates are highest among people who are diagnosed with what we call Bipolar depression. So recognizing depression and knowing how to get help are important.

Clinical depression can vary in severity, but always, it is much more than sadness. When we are depressed, we lose the ability to experience pleasure or even be interested in things we have always enjoyed and cared about. We lose motivation and energy; we feel so tired. We feel painful, grinding anxiety. Sleep is disrupted; changes in appetite lead to weight gain or loss; we lose sexual interest. We have difficulty concentrating, thinking, remembering. We feel helpless, and hopeless. Most painfully, we can feel inadequate, even worthless. We castigate ourselves for our “weakness” in being depressed, in being unable to handle life as others do. We withdraw from relationships. In severe depression, we lose the ability to work and to take care of ourselves and our families. Depression can feel unbearable, and then we can engage in self-harming behaviors with alcohol, drugs, sometimes suicide attempts.

Depression is terribly dark, lonely place.

And yet, as is the case with anxiety, we know how to treat depression. Sadly, half of people with serious depression never get treatment, and a third of people who are treated are undertreated.

Depression has many causes, both biological and psychological: it can be brought on by genetic triggers, hormones (as in postpartum depression), hormone deficiencies (as in hypothyroidism), serious illness, sometimes medications, alcohol or other recreational drugs, sleep deprivation, even by environmental factors, as in seasonal depression. Depression can be caused by major life changes, by loss, by major disappointment, by interpersonal conflicts, by abuse, by social isolation. So it is important, when seeking treatment, to be sure your clinician investigates both biological and psychosocial factors that can contribute to your symptoms. Often, it is important to have a psychiatric as well as a psychological evaluation to assess possible medical issues and the need for pharmacological or other medical treatment. Depression itself, whether biologically or psychologically caused, is a function of changes in brain activity and brain chemistry. When depression is severe, the use of antidepressant medication to counter the biological effects of depression can be critical to making psychotherapy work well, or work at all. Other newer treatments, such as Transcranial Magnetic Stimulation (TMS) and ketamine infusions, are showing success in treating depression that has been intractable to other treatment.

Research and clinical experience clearly indicate that a combination of medication and psychotherapy is most effective for serious depression. There is most research support for cognitive-behavioral therapy, but other forms of therapy can be effective as well. Psychotherapy is important for having a relationship of acceptance, positive regard, support and guidance in recovery; for maintaining hope; and for learning ways of thinking and acting, and how to make life changes that need to be made, to speed recovery and protect against depression recurring in the future. With less severe depression, or depression which is clearly caused by life stress, negative thinking patterns, and insufficient coping, psychotherapy alone is effective, and itself makes changes in brain functioning needed for recovery.

Therapy for depression includes cognitive and imaginative restructuring, and learning mindfulness. It teaches how to manage the internal “negative voices” maintaining depression and how to replace them with internal self-supportive voices that create hope and guide positive change. It includes learning how to engage, in small steps, in positive behaviors regardless of one’s feelings in the moment. It includes learning how to manage the anxiety that often comes with depression.

Learning to recover from depression and prevent its recurrence takes commitment, time and practice, at home as well as in therapy sessions. Today there are apps and digital programming that can help, and using these easily available resources can greatly speed therapeutic progress. The reward of psychotherapy for depression is the lightening of its terrible burden, and the experience of new energy, new positive feelings about oneself, new confidence in one’s ability to engage successfully in the relationships and activities in life one loves.