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Depression

What is depression?

Everyone feels sad or low sometimes, but these feelings usually pass. Depression (also called major depression, major depressive disorder, or clinical depression) is different. It can cause severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working.

Depression can affect anyone regardless of age, sex, race or ethnicity, income, culture, or education. Research suggests that genetic, biological, environmental, and psychological factors play a role in the disorder.

Women are diagnosed with depression more often than men, but men can also be depressed. Because men may be less likely to recognize, talk about, and seek help for their negative feelings, they are at greater risk of their depression symptoms being undiagnosed and under treated.

In addition, depression can co-occur with other mental disorders or chronic illnesses, such as diabetes, cancer, heart disease, and chronic pain. Depression can make these conditions worse and vice versa. Sometimes, medications taken for an illness cause side effects that contribute to depression symptoms as well.

What are the different types of depression?

The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies depressive disorders as the following:

Clinical depression (major depressive disorder): A diagnosis of major depressive disorder means you’ve felt sad, low or worthless most days for at least two weeks while also having other symptoms such as sleep problems, loss of interest in activities or change in appetite. This is the most severe form of depression and one of the most common forms.

Persistent depressive disorder (PDD): Persistent depressive disorder is mild or moderate depression that lasts for at least two years. The symptoms are less severe than major depressive disorder. Healthcare providers used to call PDD dysthymia.

Disruptive mood dysregulation disorder (DMDD): DMDD causes chronic, intense irritability and frequent anger outbursts in children. Symptoms usually begin by the age of 10.

Premenstrual dysphoric disorder (PMDD): With PMDD, you have premenstrual syndrome (PMS) symptoms along with mood symptoms, such as extreme irritability, anxiety or depression. These symptoms improve within a few days after your period starts, but they can be severe enough to interfere with your life.

Depressive disorder due to another medical condition: Many medical conditions can create changes in your body that cause depression. Examples include hypothyroidism, heart disease, Parkinson’s disease and cancer. If you’re able to treat the underlying condition, the depression usually improves as well.

There are also specific forms of major depressive disorder, including:

Seasonal affective disorder (seasonal depression): This is a form of major depressive disorder that typically arises during the fall and winter and goes away during the spring and summer.

Prenatal depression and postpartum depression: Prenatal depression is depression that happens during pregnancy. Postpartum depression is depression that develops within four weeks of delivering a baby. The DSM refers to these as “major depressive disorder (MDD) with peripartum onset.”

Atypical depression: Symptoms of this condition, also known as major depressive disorder with atypical features, vary slightly from “typical” depression. The main difference is a temporary mood improvement in response to positive events (mood reactivity). Other key symptoms include increased appetite and rejection sensitivity.

People with bipolar disorder also experience episodes of depression in addition to manic or hypomanic episodes.

Causes

It's not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

Biological differences. People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.

Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.

Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.

Inherited traits. Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.

Risk factors

Depression often begins in the teens, 20s or 30s, but it can happen at any age. More women than men are diagnosed with depression, but this may be due in part because women are more likely to seek treatment.

Factors that seem to increase the risk of developing or triggering depression include:

Certain personality traits, such as low self-esteem and being too dependent, self-critical or pessimistic

Traumatic or stressful events, such as physical or sexual abuse, the death or loss of a loved one, a difficult relationship, or financial problems

Blood relatives with a history of depression, bipolar disorder, alcoholism or suicide

Being lesbian, gay, bisexual or transgender, or having variations in the development of genital organs that aren't clearly male or female (intersex) in an unsupportive situation

History of other mental health disorders, such as anxiety disorder, eating disorders or post-traumatic stress disorder

Abuse of alcohol or recreational drugs

Serious or chronic illness, including cancer, stroke, chronic pain or heart disease

Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before stopping any medication)

Who does depression affect?

Depression can affect anyone — including children and adults.

Having certain risk factors makes it more likely that you may develop depression.

For example, the following conditions are associated with higher rates of depression:

Neurodegenerative diseases like Alzheimer’s disease and Parkinson’s disease.

Stroke.

Multiple sclerosis.

Seizure disorders.

Cancer.

Macular degeneration.

Chronic pain.

What are the signs and symptoms of depression?

Common signs and symptoms of depression include:

Persistent sad, anxious, or “empty” mood

Feelings of hopelessness or pessimism

Feelings of irritability, frustration‚ or restlessness

Feelings of guilt, worthlessness, or helplessness

Loss of interest or pleasure in hobbies and activities

Fatigue, lack of energy, or feeling slowed down

Difficulty concentrating, remembering, or making decisions

Difficulty sleeping, waking too early in the morning, or oversleeping

Changes in appetite or unplanned weight changes

Physical aches or pains, headaches, cramps, or digestive problems without a clear physical cause that do not go away with treatment

Thoughts of death or suicide or suicide attempts

Depression can also involve other changes in mood or behavior that include:

Increased anger or irritability

Feeling restless or on edge

Becoming withdrawn, negative, or detached

Increased engagement in high-risk activities

Greater impulsivity

Increased use of alcohol or drugs

Isolating from family and friends

Inability to meet responsibilities or ignoring other important roles

Problems with sexual desire and performance

Depression symptoms in children and teens

Common signs and symptoms of depression in children and teenagers are similar to those of adults, but there can be some differences.

In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.

In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using recreational drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.

Depression symptoms in older adults

Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as:

Memory difficulties or personality changes

Physical aches or pain

Fatigue, loss of appetite, sleep problems or loss of interest in sex — not caused by a medical condition or medication

Often wanting to stay at home, rather than going out to socialize or doing new things

Suicidal thinking or feelings, especially in older men

Not everyone who is depressed shows all these symptoms. Some people experience only a few symptoms, while others experience many. Depression symptoms interfere with day-to-day functioning and cause significant distress for the person experiencing them.

If you show signs or symptoms of depression and they persist or do not go away, talk to a health care provider. If you see signs of depression in someone you know, encourage them to seek help from a mental health professional.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide and Crisis Lifeline at 988 or chat at 988lifeline.org .

In life-threatening situations, call 911.

How is depression diagnosed?

To be diagnosed with depression, a person must have symptoms most of the day, nearly every day, for at least 2 weeks. One of the symptoms must be a depressed mood or a loss of interest or pleasure in most activities. Children and adolescents may be irritable rather than sad.

Although several persistent symptoms, in addition to low mood, are required for a depression diagnosis, people with only a few symptoms may benefit from treatment. The severity and frequency of symptoms and how long they last vary depending on the person.

If you think you may have depression, talk to a health care provider, such as a primary care doctor, psychologist, or psychiatrist. During the visit, the provider may ask when your symptoms began, how long they have lasted, how often they occur, and if they keep you from going out or doing your usual activities. It may help to take some notes about your symptoms before the visit.

Certain medications and medical conditions, such as viruses or thyroid disorders, can cause the same symptoms as depression. A provider can rule out these possibilities by doing a physical exam, interview, and lab tests.

Your doctor may determine a diagnosis of depression based on:

Physical exam. Your doctor may do a physical exam and ask questions about your health. In some cases, depression may be linked to an underlying physical health problem.

Lab tests. For example, your doctor may do a blood test called a complete blood count or test your thyroid to make sure it's functioning properly.

Psychiatric evaluation. Your mental health professional asks about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions.

DSM-5. Your mental health professional may use the criteria for depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

How common is depression?

Depression is common. Researchers estimate that nearly 7% of adults in the United States have depression every year. More than 16% of U.S. adults — around 1 in 6 people — will experience depression at some point in their lifetime.

However, researchers believe that these estimates are lower than reality, as many people don’t seek medical help for symptoms of depression and don’t receive a diagnosis.

Approximately 4.4% of children in the United States have depression.

Does depression look the same in everyone?

Depression can affect people differently depending on their age.

Children may be anxious or cranky, pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die.

Older children and teens may get into trouble at school, sulk, be easily frustrated‚ feel restless, or have low self-esteem. They may have other disorders, such as anxiety, an eating disorder, attention-deficit/hyperactivity disorder, or substance use disorder. Older children and teens are also more likely to experience excessive sleepiness (called hypersomnia) and increased appetite (called hyperphagia).

Young adults are more likely to be irritable, complain of weight gain and hypersomnia, and have a negative view of life and the future. They often have other disorders, such as generalized anxiety disorder, social phobia, panic disorder, or substance use disorder.

Middle-aged adults may have more depressive episodes, decreased libido, middle-of-the-night insomnia, or early morning waking. They often report stomach problems, such as diarrhea or constipation.

Older adults often feel sadness, grief, or other less obvious symptoms. They may report a lack of emotions rather than a depressed mood. Older adults are also more likely to have other medical conditions or pain that can cause or contribute to depression. Memory and thinking problems (called pseudodementia) may be prominent in severe cases.

Depression can also look different in men versus women, such as the symptoms they show and the behaviors they use to cope with them. For instance, men (as well as women) may show symptoms other than sadness, instead seeming angry or irritable.

For some people, symptoms manifest as physical problems (for example, a racing heart, tightened chest, chronic headaches, or digestive issues). Many men are more likely to see a health care provider about these physical symptoms than their emotional ones. While increased use of alcohol or drugs can be a sign of depression in any person, men are also more likely to use these substances as a coping strategy.

How is depression treated?

Depression treatment typically involves psychotherapy (in person or virtual), medication, or both. If these treatments do not reduce symptoms sufficiently, brain stimulation therapy may be another option.

Choosing the right treatment plan is based on a person’s needs, preferences, and medical situation and in consultation with a mental health professional or a health care provider. Finding the best treatment may take trial and error.

For milder forms of depression, psychotherapy is often tried first, with medication added later if the therapy alone does not produce a good response. People with moderate or severe depression usually are prescribed medication as part of the initial treatment plan.

Psychotherapy

Psychotherapy (also called talk therapy or counseling) can help people with depression by teaching them new ways of thinking and behaving and helping them change habits that contribute to depression. Psychotherapy occurs under the care of a licensed, trained mental health professional in one-on-one sessions or with others in a group setting.

Psychotherapy can be effective when delivered in person or virtually via telehealth. A provider may support or supplement therapy using digital or mobile technology, like apps or other tools.

Evidence-based therapies to treat depression include cognitive behavioral therapy and interpersonal therapy. Using other forms of psychotherapy, such as psychodynamic therapy, for a limited time also may help some people with depression.

Cognitive behavioral therapy (CBT): With CBT, people learn to challenge and change unhelpful thoughts and behaviors to improve their depressive and anxious feelings. Recent advances in CBT include adding mindfulness principles and specializing the therapy to target specific symptoms like insomnia.

Interpersonal therapy (IPT): IPT focuses on interpersonal and life events that impact mood and vice versa. IPT aims to help people improve their communication skills within relationships, form social support networks, and develop realistic expectations to better deal with crises or other issues that may be contributing to or worsening their depression.

Medication

Antidepressants are medications commonly used to treat depression. They work by changing how the brain produces or uses certain chemicals involved in mood or stress.

Antidepressants take time—usually 4−8 weeks—to work, and problems with sleep, appetite, and concentration often improve before mood lifts. Giving a medication a chance to work is important before deciding whether it is right for you.

Treatment-resistant depression occurs when a person doesn’t get better after trying at least two antidepressants. Esketamine is a medication approved by the U.S. Food and Drug Administration (FDA) for treatment-resistant depression. Delivered as a nasal spray in a doctor’s office, clinic, or hospital, the medication acts rapidly, typically within a couple of hours, to relieve depression symptoms. People will usually continue to take an antidepressant pill to maintain the improvement in their symptoms.

Another option for treatment-resistant depression is to combine an antidepressant with a different type of medication that may make it more effective, such as an antipsychotic or anticonvulsant medication.

All medications can have side effects. Talk to a health care provider before starting or stopping any medication.

Note: In some cases, children, teenagers, and young adults under 25 years may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. The FDA advises that patients of all ages taking antidepressants be watched closely, especially during the first few weeks of treatment.

Information about medication changes frequently. Learn more about specific medications like esketamine, including the latest approvals, side effects, warnings, and patient information, on the FDA website .

Brain stimulation therapy

Brain stimulation therapy is an option when other depression treatments have not worked. The therapy involves activating or inhibiting the brain with electricity or magnetic waves.

Although brain stimulation therapy is less frequently used than psychotherapy and medication, it can play an important role in treating depression in people who have not responded to other treatments. The therapy generally is used only after a person has tried psychotherapy and medication, and those treatments usually continue. Brain stimulation therapy is sometimes used as an earlier treatment option when severe depression has become life-threatening, such as when a person has stopped eating or drinking or is at a high risk of suicide.

The FDA has approved several types of brain stimulation therapy. The most used are electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). Other brain stimulation therapies are newer and, in some cases, still considered experimental. Learn more about brain stimulation therapies.

Natural products

The FDA has not approved any natural products for treating depression. Although research is ongoing and findings are inconsistent, some people report that natural products, including vitamin D and the herbal dietary supplement St. John’s wort, helped their depression symptoms. However, these products can come with risks, including, in some cases, interactions with prescription medications.

Do not use vitamin D, St. John’s wort, or other dietary supplements or natural products without first talking to a health care provider. Rigorous studies must test whether these and other natural products are safe and effective.

Hospital and residential treatment

In some people, depression is so severe that a hospital stay is needed. This may be necessary if you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

Medications for Major Depressive Disorder

The medications listed below are related to or used in the treatment of this condition

Drug name	Rating	Rx/OTC	Preg	CSA	Alcohol
Wellbutrin XL	7.4	Rx	C	N	X
Zoloft	6.8	Rx	C	N	X
bupropion	6.9	Rx	C	N	X
Prozac	6.4	Rx	C	N	X
Lexapro	6.5	Rx	C	N	X
Trintellix	6.2	Rx	C	N	X
Rexulti	6.6	Rx		N	X
sertraline	6.8	Rx	C	N	X
Cymbalta	6.2	Rx	C	N	X
Abilify	6.1	Rx	C	N	X
Pristiq	6.3	Rx	C	N	X
Vraylar	7.2	Rx		N	X
Effexor XR	6.6	Rx	C	N	X
trazodone	6.3	Rx	C	N	X
brexpiprazole	6.5	Rx		N	X
Remeron	7.4	Rx	C	N	X
Wellbutrin SR	7.9	Rx	C	N	X
fluoxetine	6.6	Rx	C	N	X
venlafaxine	6.5	Rx	C	N	X
cariprazine	7.2	Rx		N	X
mirtazapine	7.0	Rx	C	N	X
duloxetine	6.2	Rx	C	N	X
escitalopram	6.6	Rx	C	N	X
Viibryd	5.5	Rx	C	N	X
Effexor	5.8	Rx	C	N	X
aripiprazole	6.2	Rx	C	N	X
quetiapine	6.6	Rx	C	N	X
Seroquel XR	6.4	Rx	C	N	X
Paxil	7.2	Rx	D	N	X
Auvelity	8.5	Rx		N	X
nefazodone	8.9	Rx	C	N	X
Zyprexa	5.2	Rx	C	N	X
vortioxetine	6.3	Rx	C	N	X
Fetzima	5.3	Rx	C	N	X
paroxetine	7.5	Rx	D	N	X
Aplenzin	8.5	Rx	C	N	X
desvenlafaxine	6.2	Rx	C	N	X
Budeprion SR	6.0	Rx	C	N	X
doxepin	7.6	Rx	N	N	X
olanzapine	5.8	Rx	C	N	X
Paxil CR	10	Rx	D	N	X
Forfivo XL		Rx	C	N	X
vilazodone	5.5	Rx	C	N	X
Irenka		Rx	C	N	X
Raldesy		Rx	C	N	X
Spravato	7.2	Rx		3	X
bupropion / dextromethorphan	8.5	Rx		N	X
fluoxetine / olanzapine	7.8	Rx	C	N	X
Remeron SolTab	7.0	Rx	C	N	X
Emsam	6.6	Rx	C	N	X
esketamine	7.1	Rx		3	X
Opipza		Rx	C	N	X
Symbyax	7.0	Rx	C	N	X
levomilnacipran	5.3	Rx	C	N	X
selegiline	6.5	Rx	C	N	X
Exxua		Rx		N
gepirone		Rx		N

Legend
Rating	For ratings, users were asked how effective they found the medicine while considering positive/adverse effects and ease of use (1 = not effective, 10 = most effective).
Rx	Prescription only.
OTC	Over-the-counter.
Rx/OTC	Prescription or Over-the-counter.

Pregnancy Category		Controlled Substances Act (CSA) Schedule		Alcohol
B	Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.	U	CSA Schedule is unknown.	X	Interacts with Alcohol.
C	Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use in pregnant women despite potential risks.	N	Is not subject to the Controlled Substances Act.

Complications

Depression is a serious disorder that can take a terrible toll on you and your family. Depression often gets worse if it isn't treated, resulting in emotional, behavioral and health problems that affect every area of your life.

Examples of complications associated with depression include:

Excess weight or obesity, which can lead to heart disease and diabetes

Pain or physical illness

Alcohol or drug misuse

Anxiety, panic disorder or social phobia

Family conflicts, relationship difficulties, and work or school problems

Social isolation

Suicidal feelings, suicide attempts or suicide

Self-mutilation, such as cutting

Premature death from medical conditions

How can I take care of myself?

Most people with depression benefit from mental health treatment. Once you begin treatment, you should gradually start to feel better. Go easy on yourself during this time. Try to do things you used to enjoy. Even if you don’t feel like doing them, they can improve your mood.

Depression generally isn't a disorder that you can treat on your own. But in addition to professional treatment, these self-care steps can help:

Stick to your treatment plan. Don't skip psychotherapy sessions or appointments. Even if you're feeling well, don't skip your medications. If you stop, depression symptoms may come back, and you could also experience withdrawal-like symptoms. Recognize that it will take time to feel better.

Learn about depression. Education about your condition can empower you and motivate you to stick to your treatment plan. Encourage your family to learn about depression to help them understand and support you.

Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your depression symptoms. Make a plan so that you know what to do if your symptoms get worse. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Ask relatives or friends to help watch for warning signs.

Avoid alcohol and recreational drugs. It may seem like alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or substance use.

Take care of yourself. Eat healthy, be physically active and get plenty of sleep. Consider walking, jogging, swimming, gardening or another activity that you enjoy. Sleeping well is important for both your physical and mental well-being. If you're having trouble sleeping, talk to your doctor about what you can do.

Prevention

Can I prevent depression?

You can’t always prevent depression, but you can help reduce your risk by:

Take steps to control stress, to increase your resilience and boost your self-esteem.

Reach out to family and friends, especially in times of crisis, to help you weather rough spells

Get treatment at the earliest sign of a problem to help prevent depression from worsening.

Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.

If you’ve had depression before, you may be more likely to experience it again. If you have depression symptoms, get help as soon as possible.

Prognosis

What is the prognosis of depression?

The prognosis (outlook) of depression varies depending on certain factors, including:

Its severity and type.

If it’s temporary or long-lasting.

If it’s treated or untreated.

If you have co-occurring conditions, such as other mood disorders, medical conditions or substance use disorder.

With proper diagnosis and treatment, the vast majority of people with depression live healthy, fulfilling lives. Depression can return after you get treatment, though, so it’s important to seek medical help as soon as symptoms begin again.

Without treatment, depression can:

Become worse.

Increase your chance of other health conditions, like dementia.

Lead to the worsening of existing health conditions, like diabetes or chronic pain.

Lead to self-harm or death.

Depression accounts for nearly 40,000 cases of suicide each year in the United States. It’s essential to get medical help as soon as possible if you’re having suicidal thoughts. Call 911 or 988 (the Suicide and Crisis Lifeline) or go to the emergency room.

How can I find help for depression?

The Substance Abuse and Mental Health Services Administration (SAMHSA) also has an online tool to help you find mental health services in your area.

Living With Depression

When should I see my healthcare provider about depression?

If you have symptoms of depression, see a healthcare provider or mental health professional. They can give you an accurate diagnosis and suggest treatment options. If you’ve started treatment for depression and it isn’t working or you’re having unpleasant side effects, talk to your provider. They can recommend a different treatment plan. If you're reluctant to seek treatment, talk to a friend or loved one, any health care professional, a faith leader, or someone else you trust.

When to get emergency help

If you think you may hurt yourself or attempt suicide, call 911 in the U.S. or your local emergency number immediately.

Also consider these options if you're having suicidal thoughts:

Call your doctor or mental health professional.

Contact a suicide hotline.

In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, Available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

U.S. veterans or service members who are in crisis can call 988 and then press “1” for the Veterans Crisis Line. Or text 838255. Or chat online.

The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 1-888-628-9454 (toll-free).

Reach out to a close friend or loved one.

Contact a minister, spiritual leader or someone else in your faith community.

If you have a loved one who is in danger of suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

How can I help a loved one who is depressed?

If someone you know is depressed, help them see a health care provider or mental health professional. You also can:

Offer support, understanding, patience, and encouragement.

Invite them out for walks, outings, and other activities.

Help them stick to their treatment plan, such as setting reminders to take prescribed medications.

Make sure they have transportation or access to therapy appointments.

Remind them that, with time and treatment, their depression can lift.

One Final Note..

Depression is a common condition that affects millions of people every year. Anyone can experience depression — even if there doesn’t seem to be a reason for it. The good news is that depression is treatable. If you have symptoms of depression, talk to your healthcare provider. The sooner you get help, the sooner you can feel better.

Treatment of depression has become quite sophisticated and effective. The prognosis with treatment is excellent. The intensity of symptoms and the frequency of episodes often are significantly reduced. Many people recover completely.

When treatment is successful, it is important to stay in close touch with your doctor or therapist, because maintenance treatment is often required to prevent depression from returning.

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